Nt1310 Unit 1 Test 2

Test 2
Topic IV: Infection/Wound
Table 31-2 Nosocomial Infections
Site Most common Microorganisms Causes
Urinary Tract Escherichia coli, Enterococcus species.
Pseudomonas aeruginosa Improper catheterization technique, contamination of closed drainage system, inadequate hand cleansing
Surgical sites Staphylococcus aureus (including MRSA). Enterococcus species (including VRE). Pseudomonas aeruginosa Inadequate hand cleansing, improper dressing change technique
Bloodstream Coagulase-negative. Staphylococci. Staphylococcus aureus. Enterococcus species Inadequate hand cleansing, improper intravenous fluid, tubing, & site care technique
Pneumonia Staphylococcus aureus. Pseudomonas aeruginosa. Enterobacter species Inadequate hand cleansing,
improper suctioning technique

1 Introduction & body defense mechanisms o Definitions
 Infection
• Invasion of body tissue by microbes, & their subsequent proliferation
 Growth in that tissue
 Asymptomatic/subclinical
• S/S so mild that it doesn’t alert pt enough to go to MD
 Example
 CMV (Cytomegalovirus)
 Part of the Herpesvirus group
 Disease
• Detectable alteration in normal tissue function
 Virulence
• Ability of microorganism to produce disease
 Normal flora
• Normal microbes in body
• Can help or could be harmful
 Normal defenses
• Guard us against invasion &/or proliferation of microbes
 Inflammation
• Response to injury
 Dilutes invaders & destroys microbes & promotes the repair of tissue
 Inflammation doesn’t mean infection
 Protection against infection
 Immune System
• Specific defenses
• Resistance of body to infection
 Active Immunity
• Protection provided by our own bodies
• Usually lasts a long time, possibly lifetime
• You are give antigen & make your own antibody
 Nosocomial infections
• Acquired in hospital & are more virulent than other organisms in normal world because they have become resistant to many meds given in hospital
 Pts & workers can get these
 Iatrogenic infections
• Caused because of medical treatments
 IVs
 Preventable
 Medical asepsis
• Limiting number of organisms
• Removes as many as possible
 Not sterilized
 Surgical asepsis
• Make an area totally free of microbes
 Sterile dressing & gloves
 Barrier technique
• Protects pt from nurse or anyone who walks in
• Used on those c compromised immune system
 CA
 Burns
 AIDS
 Decreased WBC
 Neutropenic
• Compromised immune system b/c of low numbers of neutrophils
 Wounds
• Includes any injury to body either internal or external
• Protective barriers are compromised
• Inflammation process has begun
 Closed wound
• No break in skin
• Closed head injury c brain
 Open wound
• Break in skin or membranes
 Acute wound
• Occurs & heals in timely way
• Function is restored
 Chronic wound
• Fails to heal in timely/orderly way
• Difficult, long-term process
 Decubitus ulcers
 Keloids
• Abnormal excess of collagen formation
• Dark skin more vulnerable to this
• Can be removed cosmetically o 4 Types of Microorganisms
 Bacteria
• Most common
• Can live & be transported through air, water, food, soil, body tissues & inanimate objects
 Staphylococcus aureus
 Staphylococcus epidermis
 Escherichia coli
 Viruses
• Consist primarily of nucleic acid & therefore must enter living cells in order to reproduce
 Rhinovirus (common cold)
 Herpes
 Hepatitis
 HIV
 Fungi
• Include yeast & molds
 Candida albicans (vaginal flora)
 Parasites
• Live on other living organisms
 Malaria o Body Defense Mechanisms
 Non-specific defenses
• Protect against microbes
• Skin
 Intact, dry
• Nose
 Cillia, mucus & turbinates
• Mouth
 Shedding of mucus membranes
• Eyes
 Tears, lashes, blinking
• GI tract
 Hyperacidity
• Vagina
 Hyperacidity
 Inflammatory response
• Five signs of inflammation
 Pain
 Swelling
 Redness
 Heat
 Decreased function of affected part
• 3 steps in inflammatory response
 Vascular & cellular response
 Blood vessels initially constrict
 Followed immediately by vasodilatation
 2 to release of histamine
 Increase in blood flow to injured area
 AKA reactive hyperemia
 Responsible for characteristic sign of redness & heat
 Edema
 Increase in vascular permeability
• Allows fluid, proteins & leukocytes (WBCs) to leak into interstitial spaces
• Responsible for signs swelling & pain
 Leukocytosis
 Large numbers of leukocytes released by bone marrow into bloodstream to replace exiting leukocytes
• Normal WBC count 4500-11,000 per cubic millimeter
 Exudate stage
 Barrier formed
 Invader digested by phagocytic cells
 Exudates material that has escaped from blood vessels
 Serous
• Clear portion of blood
• Watery
 Purulent
• Contains leukocytes, debris & living bacteria
• Also known as “pus”
• Can be different colors
• Green, yellow, etc. (organism dependent)
 Sanquinous
• Contains large amounts of blood cells indicating damage to capillaries
 Combination
• Serosanguinous & purosanguious
 Reparative stage
 Repair of destroyed tissue by regeneration
 Granulation tissue
 Tissues are replaced c connective tissue elements of collagen, blood capillaries, lymphatics & other tissue-bound substances
• Early stages of regeneration
 Scar
 Tissue then shrinks & firmer fibrous tissue remains
• Last stage of regeneration
 Specific defenses
• Defend against certain identifiable bacteria, fungi, etc.
• Involves immune system
• Immunity
 Resistance of body to infection
• Antibody-mediated responses
 Production of antibodies (also called immunoglobulins) in response to natural or artificial antigens (i.e. microorganisms or vaccines)
 B cells are activated (bone marrow)
 IgM
 Marker for current infection
 IgG
 Crosses placenta
 IgA
 Most abundant in breast milk
 IgD
 Does activates B cells
 IgE
 Allergic rxn
• Cell-mediated responses
 Cell-mediated defenses or cellular immunity occur through T-cell system
 Exposure of an antigen
 Lymphoid tissues release large numbers of T cells into lymph system
 Three main groups of T cells
 Helper T cells
 Help immune function
 Cytoxic T cells
 Attack & kill microbes
 Suppressor T cells
 Suppress cytoxic and helper T cells
 Cell mediated immunity is lost c HIV
 Two types of immunity
• Active immunity
 Protection provided by our own bodies
 Lasts a long time
 Natural antibodies: host produces antibodies in response to natural antigens
 In response to infection
 Artificial antibodies: given antigens make our own antibodies
 In response to vaccines
• Passive immunity
 Protection received from another source
 Usually short lived
 May be human or animal
 Natural antibodies come from natural sources
 Mother to child in utero or through breast milk
 Artificial antibodies come from injection of an antibody from an immune serum
 Human or animal
• Snake venom antitoxin (antibody)

Table 31-4 Types of Immunity p.674
Type Antigen or Antibody source Duration
Active Antibodies are produced by the body in response to an antigen. Long
-Natural Antibodies are formed in the presence of active infection in the body. Lifelong
-Artificial Antigens (vaccines or toxoids) are administered to stimulate antibody production. Many years; the immunity must be reinforced by booster
Passive Antibodies are produced by another source, animal or human. Short
-Natural Antibodies are transferred naturally from an immune mother to her baby through the placenta or in colostrums. 6 months to 1 year
-Artificial Immune serum (antibody) from an animal or another human is injected. 2-3 weeks

2 Chain of infection & types of infection o Six links make up chain of infection
 Figure 31-1 Chain of infection p. 671 o Etiologic agent (causative agent/pathogen)
 Causative agent or pathogen must exist first (bacteria, virus, fungus or parasite)
 Virulence
• Some agents are more capable of producing an infection than others
 Number of microorganisms present
 Ability of the microorganism to enter the body o Reservoir
 Source of microorganism
 Other humans, pt’s own microorganisms, plants, animals or environment (soil, food, water, feces)
 People are most common source of infection for others & themselves
 Carrier
 A person or animal reservoir of specific infectious agent that does not manifest any clinical signs of disease
 Anopheles mosquito carries the malaria parasite but not affected by it
 Carrier state is clinically visible in dog c rabies o Portal of exit
 Before an infection can establish itself in a host, the microorganism must leave the reservoir
 In human, this can be from respiratory, GI or GU tracts, during reproduction, blood lesions on skin, or across placenta o Method/mode of transmission
 Three methods of transmission
 Direct transmission
• Involves immediate or direct transfer of microorganism from person to person
 Touching, biting, kissing or sexual intercourse
 Droplet spread is also a form of direct transmission but can occur only if the source & the host are cin 3 feet of each other
 Sneezing
 Coughing
 Spitting
 Singing
 Talking can project droplet spray
 Indirect transmission
• Vehicle-borne
 Any substance that serves as go-between from the source to the host
 Fomite
 Inanimate material or object; toys, IV needles, doorknobs, & handkerchiefs
• Vector-borne
 Animal or flying or crawling insect that serves as an intermediate means of transporting infectious agent
 Airborne transmission
• Droplets
 Residue of an infected host can remain in air for long periods of time & can be carried by an air current to suitable portal of entry
 TB
• Dust
 Particles containing an infectious agent can also become airborne
 C-diff (clostridium difficile) spores in soil o Portal of entry
 Before person can become infected, microorganisms must enter body
 Any break in skin integrity can serve as portal of entry
 Often, microorganisms enter body of host by same route they used to leave source o Susceptible host
 Any person at risk for infection
 Just because pathogen gains entry does not mean it will proliferate & cause infection
 A compromised host more at risk
• Compromised host
 Age
 Very young & very old
 Immune status
 HIV, DM, CA, chronic diseases
 Therapeutic Tx
 Radiation, chemotherapy
 Medications
 Antibiotics
 Decrease normal flora
 Anti-inflammatory
 Steroids
• Decrease inflammation response as well as increase blood glucose
 Surgery/trauma/burns
 Impair skin integrity
 Decreased nutritional status
 Lack of adequate protein in diet can reduce number of B-cell & T-cell proteins circulating in body
 Invasive lines that break primary line of defense
 Decreased mobility
 Skin breakdown
 Stagnant secretions create an optimum environment for microorganism growth o Breaking chain of infection
 Cleaning
• Disinfection
• Sterilization
 Hygiene
• Dressing changes
• Disposal of fluid container
• Change soiled linen
• Cover mouth & nose when coughing & sneezing
• Hand washing
• Med/surg asepsis
• Wear gloves, gowns, mask, & goggles
• Proper disposal of sharps, sterile technique
 Skin integrity
• Balanced nutrition
• Exercise
 Intact immune system o Nosocomial Infections
 Classified as infections associated c delivery of health care services in health care settings
 Occurs b/c of presence of pathogens & susceptible host
 Most common sites
• Urinary tract
• Respiratory tract
• Bloodstream
• Wounds
 Types of nosocomial infections
• Endogenous: pt infects themselves
• Exogenous: hospital environment/personnel infect pt
• Iatrogenic: direct result of diagnostic/therapeutic procedures
 Inadequate hand washing
 Improper diagnostic procedure
 Protocol not followed

Table 31-7 p. 683 Nursing interventions that break chain of infection
Link
Interventions Rationales
Etiologic agent (microorganisms) -Ensure that articles are correctly cleaned & disinfected or sterilized before use
-Educate pts & support persons about appropriate methods to clean, disinfect, & sterilize articles -Correct cleaning, disinfecting, & sterilizing reduces or eliminates microorganisms
-Knowledge of ways to reduce or eliminate microorganisms reduces numbers of microorganisms present & likelihood of transmission
Reservoir (source) -Change dressings & bandages when they are wet or soiled
-Assist pts to carry out appropriate skin & oral hygiene
-Dispose of damp, soiled linens appropriately
-Dispose of feces & urine in appropriate receptacles
-Ensure that all fluid containers, such as bedside water jugs & suction & drainage bottles, are covered or capped
-Empty suction & drainage bottles at the end of each shift or before they become full, or according to agency policy -Moist dressings are ideal environments for microorganisms to grow & multiply
-Hygienic measures reduce the numbers of resident & transient microorganisms & the likelihood of infection
-Damp, soiled linens harbor more microorganisms than dry linens
-Urine & feces in particular contain many
microorganisms
-Prolonged exposure increases the risk of contamination & promotes microbial growth
-Drainage harbors microorganisms that, if left for long periods, proliferate & can be transmitted to others
Portal of exit from the reservoir -Avoid talking, coughing, or sneezing over open wounds or sterile fields, & cover the mouth & nose when coughing & sneezing. -These measures limit the number of microorganisms that escape from the respiratory tract.
Method of transmission -Cleanse hands between pt contact, after touching body substances, & before performing invasive procedures or touching open wounds.
-Instruct pts & support persons to cleanse hands before handling food or eating, after eliminating, & after touching infectious material.
-Wear gloves when handling secretions & excretions.
-Wear gowns if there is danger of soiling clothing c body substances.
-Place discarded soiled materials in moisture-proof refuse bags,
-Hold used bedpans steadily to prevent spillage, & dispose of urine & feces in appropriate receptacles.
-Initiate & implement aseptic precautions for all pts.
-Wear masks & eye protection when in close contact c pts who have infections transmitted by droplets from the respiratory tract.
-Wear masks & eye protection when sprays of body fluid are possible (e.g. during irrigation procedures). -Hand cleansing is an important means of controlling & preventing the transmission of microorganisms.
-Hand cleansing helps prevent transfer of microorganisms from one person to another.
-Gloves & gowns prevent soiling of the hands & clothing.
-Moisture proof bags prevent the spread of microorganisms to others.
-Feces in particular contain many microorganisms.
-All pts may harbor potentially infectious microorganisms that can be transmitted to others.
-Masks & eye protection provide protection from microorganisms in pts’ body substances.
Portal of entry to the susceptible host -Use sterile technique for invasive procedures (e.g. injections, catheterizations).
-Use sterile technique when exposing open wounds or handling dressings.
-Place used disposable needles & syringes in puncture resistant containers for disposal.
-Provide all pts c their own personal care items. -Invasive procedures penetrate the body’s natural protective barriers to microorganisms.
-Open wounds are vulnerable to microbial infection.
-Injuries from needles contaminated by blood or body fluids from an infected pt or carrier are a primary cause of HBV & HIV transmission to health care workers.
-People have less resistance to another person’s microorganisms than to their own.

Susceptible host -Maintain the integrity of the pt’s skin & mucous membranes.
-Ensure that the pt receives a balanced diet.
-Educate the public about the importance of immunizations. -Intact skin & mucous membranes protect against invasion by microorganisms.
-A balanced diet supplies proteins & vitamins necessary to build or maintain body tissues.
-Immunizations protect people against virulent infectious diseases.

o Supporting defenses
 Hygiene
 Nutrition
 Fluid
 Sleep
 Stress
 Immunity o Growth depends on:
 Virulence of microbe
 Numbers of microbes
 Vulnerability of host
• Nearly everyone in hospital has increased vulnerability
• Read about inflammation in Kozier o Prevention & control
 Medical asepsis
• Limiting number, growth & transmission of organisms
• Confining specific microorganism to specific area
• Items are referred to as clean or dirty
 Clean
 Absence of almost all microorganisms
 Dirty
 Soiled or contaminated
 Means likely to have microorganism, some of which may be capable of causing an infection
 Disinfecting
 Bactericidal
 Kills bacteria
 Bacteriostatic
 Prevents multiplication of bacteria s destroying it
 Surgical asepsis
• Practices that keep area or object free of all microorganisms
• Aseptic technique/sterile technique
• Sterilization
 Moist heat
 Gas
 Boiling water
 Radiation
 HANDWASHING o Isolation techniques/precautions
 Isolation
• Measures designed to prevent spread of infections or potentially infectious microorganisms to health personnel, pts & visitors
 Governed by CDC; many changes over years
 Aim is to break chain of infection at transmission phase of cycle
 In 1997 CDC updated isolation precautions into two tier system
• Tier I: Standard Precautions
 Used in care of all hospitalized persons regardless of diagnosis or infection status
 Applied to all blood, body fluids, secretions, excretions whether or not blood is visible, & nonintact skin & mucus membranes
 Except sweat
• Tier II: Transmission based precautions
 Used in addition to standard precautions
 Droplet precautions
 Used for pts c known or suspected illnesses transmitted by particle droplets larger than 5 microns
 Diphtheria
 Mycoplasma pneumonia
 Pertussis
 Mumps
 Rubella
 Scarlet fever
 Airborne precautions
 Used for pt c known or suspected illness transmitted by particles less than 5 microns
 Measles
 Chickenpox
 TB
• Has special guidelines
• Pt kept in negative pressure room
 Contact precautions
 Used for pts c known or suspected illness transmitted by direct contact c pt or by contact c items in pt’s environment
 GI
 Respiratory
 Skin
 Wound infections
 MRSA
• Methicillin-resistant staphylococcus aureus
 VRE
• Vancomycin-resistant Enterococcus
 E-coli
 Hepatitis A
 Scabies
 Conjunctivitis

Box 31-1 p. 689 Recommended Isolation Precautions in Hospitals
Standard Precautions
Designed for all pts in hospital
These precautions apply to
Blood
All body fluids, excretions, & secretions except sweat
Nonintact (broken) skin
Mucous membranes
Designed to reduce risk of transmission of microorganisms from recognized & unrecognized sources.
Perform proper hand hygiene after contact c blood, body fluids, secretions, excretions, & contaminated objects whether or not gloves are worn.
Perform proper hand hygiene immediately after removing gloves.
Use nonantimicrobial product for routine hand cleansing
Use an antimicrobial agent or an antiseptic agent for the control of specific outbreaks of infection.
Wear clean gloves when touching blood body fluids, secretions, excretions, & contaminated items (e.g. soiled gowns).
Clean gloves can be unsterile unless their use is intended to prevent the entrance of microorganisms into the body.
Remove gloves before touching noncontaminated items & surfaces.
Perform proper hand hygiene immediately after removing gloves
Wear a mask, eye protection, or a face shield if splashes or sprays of blood, body fluids, secretions, or excretions can be expected.
Wear a clean, nonserile gown if pt care is likely to result in splashes or sprays of blood, body fluids, secretions, or excretions. The gown is intended to protect clothing.
Remove a soiled gown carefully to avoid the transfer of microorganisms to others (e.g. pts or other health care workers).
Cleanse hands after removing gown.
Handle pt care equipment that is soiled c blood, body fluids, secretions, or excretions carefully to prevent transfer of microorganisms to others & to environment.
Make sure reusable equipment is cleaned & reprocessed correctly
Dispose of single-use equipment correctly.
Handle, transport, & process linen that is soiled c blood, body fluids, secretions, or excretions in a manner to prevent contamination of clothing & transfer of microorganisms to others & to environment.
Prevent injuries from used scalpels, needles, or other equipment, & place in puncture-resistant container.
Transmission-Based Precautions
Airborne Precautions-Use standard precautions as well as
following:
Place pt in private room that has negative air pressure, 6-12 air changes per hour, & either discharges air to outside or filtration system for room air.
If private room is not available, place pt c another pt who is infected c same microorganism.
Wear respiratory device (N95 respirator) when entering room of pt who is known or suspected of having primary TB
Susceptible people should not enter room of pt who has rubeola (measles) or varicella (chickenpox). If they must enter, they should wear respirator.
Limit movement of pt outside room to essential purposes. Place surgical mask on pt during transport.
Droplet Precautions-Use standard precautions as well as following
Place pt in private room
If private room is not available, place pt c another pt who is infected c same microorganism.
Wear a mask if working within 3 feet of pt.
Limit movement of pt outside room to essential purposes. Place surgical mask on pt during transport.
Contact Precautions-Use standard precautions as well as the following:
Place pt in private room.
If private room is not available, place pt c another pt who is infected c same microorganism.
Wear gloves as described in standard precautions.
Change gloves after contact c infectious material.
Remove gloves before leaving pt’s room.
Cleanse hands immediately after removing gloves. Use an antimicrobial agent. Note: If pt is infected c C. difficle, do not use an alcohol-based hand rub, as it may not be effective on these spores. Use soap & water.
After hand cleansing, do not touch possibly contaminated surfaces or items in room.
Wear gown (see standard precautions) when entering room if there is possibility of contact c infected surfaces or items, or if pt is incontinent, or has diarrhea, a colostomy, or wound drainage not contained by dressing.
Remove gown in pt’s room
Make sure uniform does not contact possible contaminated surfaces
Limit movement of pt outside room.
Dedicate use of noncritical pt care equipment to single pt or to pts c same infecting microorganisms

o Barrier technique/reverse isolation
 Protects pt from nurse or anyone who enters room
 Used to protect pt especially those c compromised immune system
 High risk pts include
• CA
• Burns
• AIDS
• Chemotherapy/radiation therapy
• Low WBC count
 Personal protective equipment
• Gloves
• Gown
• Face mask
• Eyewear
3 Wounds & dressings o Definitions
 Wound
• Any injury to body internal or external
• Protective barriers are compromised
• Inflammatory process has begun
• Important nursing functions
 Maintain skin integrity
 Promote wound healing
 Intentional
• Trauma occurs during therapy
 Surgery
 Venipuncture
 Unintentional
• Wounds are accidental
 Falls
 Automobile accident
 Closed
• Tissue traumatized s break in skin
 Fracture
 Contusion
 Open
• Skin or mucus membrane surface is broken
 Acute
• Wound that occurs & heals in timely manner
• Function is restored
 Chronic
• Fails to heal in timely manner
• Difficult, long term process
 Ulcers/decubiti o Degrees of wound contamination
 Clean
• Wound contains no pathogens
• Does not enter GI, urinary, respiratory, genital tract or infected areas
• Decreased incidence of infection
• Primarily closed wounds
 Clean contaminated
• Done under aseptic conditions but involves area that has microbes
 GI tract
 Respiratory tract
 Surgical wounds
• Show no evidence of infection
 Contaminated
• Include open, fresh, accidental wounds
• Also surgical wounds involving major break in sterile technique or large amount of spillage from GI tract
• High risk for infection
• Evidence of inflammation
 Infected or dirty
• Bacterial organism present
• Contain dead tissue
• Evidence of clinical infection
 Purulent drainage
 Non-healing wound
• Surgery into infected area o Descriptive qualities
 Closed wounds
• Contusions
 Blunt trauma or blow b/c of damage to blood vessels
 Can be intentional or unintentional
• Closed fractures
 Broken bone but not skin
 Open wound
• Abrasion
 Surface scrape
 Confined to top layers of skin
 Partial thickness
 Can be intentional or unintentional
 Dermabrasion
• Laceration
 Jagged edges
 Torn apart or ripped open
 Trauma
 Usually unintentional
• Incision
 Sharp instrument used like scalpel or knife
 May be shallow or deep
 Can involve all layers
 Full thickness
 Usually intentional
• Penetrating
 Goes through skin & underlying tissues
 Even organs
 Bullet or metal fragments
 Can be intentional or unintentional
 GSW
• Puncture
 Penetration of skin & underlying tissue
 Usually not deep
 Usually small & round
 Can be intentional or unintentional
 Stepping on something
 Being poked by pin/nail
 IV o Classifying wounds by depth
 Partial thickness
• Confined to skin (dermis & epidermis)
• Healed by regeneration
 Full thickness
• Involves dermis, epidermis, subcutaneous tissue
 Possibly muscle & bone
• Requires connective tissue repair o Wound healing
 Most injuries & wounds heal & form scars
 Three types of wound healing
• Primary intention
 Closed wound edges
 Occurs when tissue edges have been approximated
 Minimal tissue loss
 Minimal formation of granulation tissue & scaring
 Closed surgical incision
 Tissue adhesive
 Liquid “glue” used to seal clean lacerations or incisions
• Secondary intention
 Significant loss of tissue
 Longer repair time
 Greater scarring
 Greater susceptibility for infection
 Eschar or dead tissue in wound must be removed for healing
 Very fragile granulation tissue forms
 Often weeps serosanquinous fluid
 Closes very slowly from outside & gets smaller & smaller
 Cannot be sutured
 Eventually form thick scars
• Tertiary intention
 Wound closure & healing delayed for reason
 Said to be secondary closure to tertiary intention or “delayed primary intention”
 Wound left open on purpose to increase drainage or improve circulation
 Suturing done later after granulation & more scar tissue forms
 May be infected
 Closing would allow abcess
 Anticipate eschar, multiple debridements or possibly soaking c various solutions
 Phases of wound healing
• Inflammatory phase
 Starts immediately after injury
 Lasts 3-6 days
 Bleeding stops
 Scabs & clots form
 Inhibits contamination
 Inflammatory process begins to flood area c nutrients & fluids
 Removes debris
 Phagocytosis occurs
 Macrophages remove debris
 May be impaired by meds such as steroids
 Impairing inflammation places healing process at risk
• Proliferative phase
 Lasts 3 or 4 to 21 days
 Collagen synthesis adds strength to wound
 Decreases chances of wound reopening
 Capillary network develops
 Tissue become translucent red color known as granulation tissue which is very fragile & bleeds easily
• Maturation phase
 Starts about day 21 up to 1 or 2 years
 Wound is remodeled & contracted
 Collagen continues to be made & scar gets stronger & stronger
 Repaired area is never as strong as original tissue
 Healing ridge where collagen & granulation are forming
 Can form keloid
 Hypertropic scar
 Seen more often in dark skinned people o Factors affecting healing
 Age
• Healthy children & adults heal more quickly than elders
• Elderly
 Chronic diseases
 Decreased skin integrity
 Impaired immune systems
 Nutritional deficiencies
 Nutrition
• Diet should be rich in
 Protein
 Carbs
 Fats
 Vitamins A & C
 Iron (Fe)
 Copper (Cu)
 Zinc (Zn)
 Lifestyle
• Regular exercise promotes good circulation
• Smoking decreases amt of functional Hgb in blood thus limiting O2 carrying capacity of blood, & constrict arterioles
 Wound stress
• Coughing, abdominal distension, vomiting
• Refer to Braden Scale for Predicting Pressure Sore Risk (figure 36-2; Kozier p. 907)
 Total of 23 possible points
 Medications
• Anti-inflammatory drugs (steroids & aspirin), & antineoplastic agents interfere c healing
• Prolonged use of antibiotics may make pt susceptible to wound infection by resistant organisms
 Infection
• If wound is contaminated c foreign material, determine when pt last had tetanus toxoid injection
 Tetanus immunization or booster may be necessary o Complications of wound healing
 Hemorrhage
• Massive bleeding
 Abnormal & Tx as emergency
 Usually caused by slipped sutures or eroded vessels
 Look for signs of shock
 LOC changes
 Diligent VS first 24 hours post-op
 Hematoma
• Localized collection of blood beneath skin
 Large hematomas may obstruct blood flow
 Dehiscence
• Usually involves an abdominal wound in which layers below skin also separate
• More likely to occur 4 to 5 days postop
 Before extensive collagen is deposited
• Indicated by increased serosanguinous fluid drainage
• Wound edges not meshed together
• Feels boggy c palpation
• Causitive factors include
 Sudden straining
 Coughing
 Sneezing
 Evisceration
• Protrusion of internal viscera through incision
• More likely to occur c
 Obese
 Poorly nourished
 Dehydration
 Multiple trauma
 Excessive coughing & vomiting
 Failed sutures
 Tx of dehiscence/evisceration
• Wound should be quickly supported by large sterile dressings soaked in sterile NS
• Place pt in bed c knees bent
 Decrease pull on incision
• Notify surgeon
 Infection
• Suggested by presence of change in wound color, pain, or drainage
• Confirmed by performing CX on wound
• Can occur anytime in post-op
 Most likely to become apparent 2-11 days post op
• More likely to occur c wounds sustained from injury
 MVA
 Knife wounds
 Abdominal wounds
 GSWs o Wound assessment parameters for infection
 Location
• Always note where it is & be specific
 Size
• Length, width, & depth of wound
• Give it in cm
 Appearance
• Color, heat, texture, firmness of surrounding area (palpate)
• Wound edges approximated or uneven
• Type of tissue
 Eschar
 Black, brown, or tan tissue
 Adheres firmly to wound bed or ulcer edges
 May be either firmer or softer than surrounding skin
 Granulation
 Pink or beefy red tissue c shiny, moist, granular appearance
 Slough
 Yellow or white tissue
 Adheres to ulcer bed in strings or thick clumps or is mucinous
 Epithelial tissue
 For superficial ulcers
 New pink or shiny tissue
 Grows in from edges or as islands on ulcer surface
 Closed/resurfaced
 Wound is completely covered c epithelium
 Intact
 Normal appearing skin c all skin layers intact
 Intact, pink, well approximated, no drainage
 Drainage
• Where is it coming from, color, consistency, odor,
• Amt on dressing &/or wound (hard to note)
 Small
 Scant
 Moderate
 Copious
 Swelling
• Sterile gloves
• Palpate for
 Tension
 Wound edges
 Softness
 Bogginess
 Hardness
 Pain
• Moderate to severe for 3-5 days
• Generally localized
• If persists, may indicate infection
 Undermining or tunneling
• Extension of wound beyond main surface
• Present/absent
• Measure involvement
 External devices
• Penrose or Jackson-Pratt drains
• Hemovac
• Document type of device & location
• Document type, color & amt of drainage
• Check that device is secure & functional
 Dressings
• Type of solution used & type of dressing applied
 LRC dressing change o Stages of decubitis ulcer
 I, II, III, IV
 Pressure ulcer:
• Previously called decubitus ulcers
• Any lesion caused by unrelieved pressure that results in damage to underlying tissue
• Most common & most preventable alterations in skin integrity
 Stage 1
• Non-blanchable reddened skin
• May be pale but turns red after pressure relieved
• Red area caused by reactive hyperemia
 Increase in blood flow to injured site providing area c O2 & nutrients
 Defense mechanism
• Lasts 1/2 to 3/4 as long as time pressure was applied to area
 Check back ½ hour to 45 minutes later if in position for 1 hr
 Probably will be no damage if redness disappears in that time
 Redness persists beyond that time, then damage likely to occur
 On left side 1 hour then redness should last 30-45 minutes
 Stage 2
• Partial thickness skin loss
• May appear like an abrasion, blister or shallow crater c pinkish-red base
• Involves epidermis & possibly dermis
• May have white or yellow discharge
 Stage 3
• Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
• Presents clinically as deep crater c or s undermining of adjacent tissue
• May appear c white-gray & yellow eschar, purulent drainage
 Stage 4
• Full thickness skin loss c tissue necrosis or damage to muscle, bone, or supporting structures, such as tendons or joint capsules
• Undermining & sinus tracts may also be present
• Foul smell
 Brown or black eschar c purulent drainage o Preventing pressure ulcers
 Providing nutrition
 Maintaining skin hygiene
 Avoiding skin trauma
 Providing supportive devices o Types of dressings
 Transparent adhesive
• Stage I & II
 Films/Wound barriers
 Adhesive plastic
 Semi-permeable
 Non-absorbent
 Allows O2 to pass
 Impermeable to H2O & bacteria
 Protects against contamination & friction
 Prevents fluid evaporation
 Provides clean moist surface for cellular migration
 Facilitates wound assessment
 Impregnated non-adherent dressings
• Woven or non-woven cotton
• Synthetic materials
• Impregnated c
 Petroleum
 Saline
 Zinc-saline
 Antimicrobials
• Need secondary dressing to secure them in place
• Retain moisture
• Provide wound protection
• Cover, soothe, & protect partial & full thickness wounds c exudate
 Hydrocolloids
• Stage II, III, & IV
 Waterproof adhesive wafers, pastes, or powders
 Wafers
 Can be worn up to 7 days
 Inner adhesive layer has particles to absorb exudate
 Form hydrated gel over wound
 Outer layer forms seal
 Absorb exudate
 Provide moist environment to facilitate healing
 No maceration (softening) of surrounding skin
 Also for partial thickness wounds
 Hydrogels
• Stage II, III, & IV
 Glycerin or water-based non-adhesive jellylike sheets, granules, or gels
 O2 permeable
 Unless covered by plastic film
 Require secondary occlusive dressing
 Liquefy necrotic tissue or slough
 Rehydrate wound bed
 Fill in dead space
 Used on
 Pressure ulcers
 Skin tears
 Partial thickness wounds
 Polyurethane Foams
• Non-adherent hydrocolloid dressings
 Need edges taped or sealed
 Require secondary dressings to obtain an occlusive environment
 Surrounding skin must be protected to prevent maceration
 Absorbs light to moderate amounts of exudate
 Debride wounds
• Used on
 Pressure ulcers
 Skin tears
 Venous stasis ulcers
 Surgical wounds
 Wounds undergoing chemical debridement
 Exudate absorbers
• Stage III & IV
• AKA Alginate
• Non-adherent dressings of powder beads, granules, or paste
 Conform to wound surface
 Absorb up to 20 times their weight in exudate
 Require secondary dressing
 Provide moist wound surface by interacting c exudate
 Form gelatinous mass
 Eliminate dead space or pack wounds
 Support debridement
 Removal of dead, damaged, or infected tissue to improve healing potential of remaining healthy tissue
• Used on
 Pressure ulcers
 Skin tears
 Venous statsis ulcers
 Surgical wounds
 Wounds undergoing chemical debridement
 Dry to dry
• Stage III & IV
 Layer of wide mesh cotton gauze
 Lies next to wound surface
 Second layer of dry absorbent cotton or Dacron
 Protect wound
 If wound open or draining
 Necrotic debris & exudate trapped in gauze & removed
 Wet to Dry
• Stage III & IV
 Next to wound surface
 Layer of gauze saturated c saline or antimicrobial solution
 Covered by moist absorbent material that is moistened c same solution
 Debride wound
 Necrotic debris is softened
 Adheres to gauze as it dries
 Removed when dressing is removed
 Moisture helps dilute viscous exudate
• Wet to Damp
 Variation of wet to dry
 Removed before it has completely dried
 Wound is debrided when gauze is removed
• Wet to Wet
 Layer of gauze saturated c antibacterial solution lies next to wound surface
 Above is second layer of absorbent material c same solution
 Kept moist c wetting agent
 Wound surface is continually bathed
 Moisture dilutes viscous exudate

Assessing Common Pressure Sites; Kozier p. 909
Position Body pressure areas to assess/inspect
Supine position Heels
Sacrum
Elbows
Scapulae
Back of head (occipital bone)

Lateral position Malleolus (medial & lateral)-ankle
Knee (medial & lateral)
Greater trochanter-hip
Ilium-superior, lateral portion of pelvic bone
Shoulder (acromial process)
Ear
Side of head (parietal & temporal bones)

Prone position Toes (phalanges)
Knees (patellas)
Genitalia (men)
Breasts (women)
Shoulder (acromial process)
Cheek & ear (zygomatic bone)

Fowler’s position (30 angle) Heels (calcaneus)
Pelvis (eschial tuberosity)
Sacrum
Vertebrae (spinal processes)

Dressings of Pressure Ulcers (look at table in Kozier)
Dressings for Pressure Ulcers Mechanism of Action Stage I Stage II Stage III Stage IV
Dry gauze Wicks drainage away from wound surface X X
Wet-to-dry gauze Maintain moist wound environment, wicks drainage away from wound surface X X
Transparent barrier Retains wound moisture, allows gas exchange, does not stick to wound surface X X
Hydrocolloid Occlusive (closes the wound, excludes it from the air), repels moisture & dirt, moist environment X X X
Hydrogel Maintain moist wound environment X X X
Alginate Maintain moist wound environment, absorbs exudates X X NOTE: Some dressings may be used on other pressure ulcer stages

Physiologic Effects of Heat & Cold (Table 36-6 Kozier pg 931)
Heat Cold
Vasodilation Vasoconstriction
Increases capillary permeability Decreases capillary permeability
Increased cellular metabolism Decreases cellular metabolism
Increased inflammation Slows bacterial growth, decreases inflammation
Sedative effect Local anesthetic effect

Mechanical devices for reducing pressure on body parts (Table 36-4; Kozier p. 921)
Device Description/comments
Gel flotation pads Polyvinyl, silicone, or silastic pads filled c a gelatinous substance similar to fat
Pillows & wedges (foam, gel, air, fluid) Supports positioning & offloads bone on bone contact
Heel protectors (sheepskin boots, padded splints, off-loading inflatable boots, foam blocks) Can raise or “float” a body part (e.g. heels) off the surface of bed. Prevent shearing & limit pressure on heel area.
Memory foam mattress/chair pad Polyurethane foam mattress distributes weight over bony areas evenly. Foam molds to the body.
Alternating pressure mattress Composed of number of cells in which the pressure alternately increases & decreases; uses a pump
(LAL) bed Support surface filled c water. Water temperature can be controlled.
Static low-air-loss Consists of many air filled cushions divided into four or five sections. Separate controls permit each section to be inflated to a different level of firmness; thus pressure can be reduced on bony prominences but increased under other body areas for support
Active or second-generation LAL bed Like the static LAL bed, but in addition gently pulsates or rotates from side to side, thus stimulating capillary blood flow & facilitating movement of pulmonary secretions
Air-fluidized (AF) bed (static high-air-loss bed) Forced temperature-controlled air is circulated around millions of tiny silicone-coated beads, producing a fluid like movement. Provides uniform maceration by its drying effect. Moisture from the pt penetrates the linens & soaks the beads. Air flow forces the beads away from the pt & rapidly dries the sheet. A major disadvantage is that the head of the bed cannot be elevated. Some beds are a unique combination of air fluidized therapy & low air loss therapy on an articulating frame. These are used c pts who require head elevation.

4 Nursing Diagnosis o High Risk for Infection
 R/T possible entry & proliferation of microorganisms
• S/T incision to LLQ of abd
 Risk factors
• Any other wounds or sites of skin breakdown
• Age
• Weight
• Nutritional status
• Chronic illness
• Skin impairment is severe
• Pt is immunosupressed
• Wound caused by trauma o Altered protection
 Too broad & shouldn’t use this o Pain
 Applies to pt c existing impaired skin or tissue integrity
 R/T nerve involvement within tissue, impairment, or as consequence of procedures used to treat wound o High risk for impaired skin integrity
 At risk of skin being adversely altered o Impaired skin integrity
 Commonly applies to pressure ulcers & to wounds extending though epidermis but not through dermis
 Generally for stage I & II o Impaired tissue integrity
 Applies to pressure ulcers & to wounds extending into subcutaneous tissue, muscle or bone
 Generally for stage III & IV
 These stages require collaboration & are also PC

Topic V: Pharmacotherapeutics/dynamics
5 Pharmacology o Study of drugs & their actions on living organisms & how they affect body cells o Most important goal is safe & accurate administration of meds o Know
 Benefits of drugs
 Harm drugs do o Know following about pt
 Current HHx
• Present circumstances
• Pain
• Nausea
• Sleep patterns
• Religious practices
 Present HHx
 Past HHx
• Past surgical procedures
• Past allergic rxns
• Chronic diseases
 Drug Hx
• Past & present (OTC, Rx, Herbs) o Pharmocotherapeutics
 Use of drugs to treat, cure, relieve, or prevent disease o Pharmacodynamics
 Process by which drug changes body o Pharmacokinetics
 Study of metabolism & actions of drugs c particular emphasis on time required for absorption, duration of action & effect, distribution in body & method of excretion o Each drug can have 4 names
 Chemical name
• Chemical make up
 Generic name
• Given before drug becomes approved medication
• Used throughout drugs use
 Official name
• Given by USP
• Often same as generic
 USP – United States Pharmacopia
 Brand name
• Trade name
• Given by manufacturer
 Ex:
• Chemical acetylsalicylic acid
• Generic Aspirin
• Official Aspirin
• Brand Bufferin, Excederin, Bayer, St. Joseph’s o Drug book has list of all brand names o Drugs classified by:
 Characterisitics
 Symptoms relieved
 Desired effects
• Aspirin is a/an:
 Analgesic
 Antipyretic
 NSAID
 Anticoagulant
 Platelet clumping reducer o Know drug characteristics & nursing considerations of drug
 Look up in drug book
 Know what drug does in body
 Know what RN has to check before & after admin
• Check lab values
• VS o Absorption (p 839 list of routes)
 Route of administration
• Rx by MD
• RN can prompt MD to change route
 Can’t change independently
• How drug gets into body will affect how it works in body
 PO
 Subcutaneous
 Buccal
 Rectal
 Vaginal
 Topical
 Transdermal
 IM
 ID
 IV
 Inhalation
 Ability of med to dissolve
• Acidity or alkalinity of drug
 Acid  stomach absorbs well
 Base better absorbed in intestines
• Plays part in where & how it is dissolved/absorbed
 Blood flow to area of absorption
• Greater vascularity greater absorption & transport through system
• Can be influenced by heat & cold
 Body surface area
• Greater area = greater absorbtion
 Reason some drugs are designed to be absorbed in intestines
 Lipid solubility of med
• Can increase or decrease amt of time needed to absorb med
 Reason whether drug taken c or s food
 Fat can act as carrier for some meds o Distribution
 After absorbed med must go to site of action
• Chemical make up determines site of action
• Pt physiologic make up affects how med works in body
 Can be affected by following
• Circulation
 High vascularity gets med before low vascularity
 Same for vasoconstriction vs vasodilation
 Affects absorbtion rate by high/low blood flow
• Membrane permeability
 Blood-brain barrier
 Allows fat soluble meds through while stopping water soluble
 Antibiotics have difficulty crossing
 Placental barrier
 Not as selective about drugs that cross to fetus
 Teratogenic
 Agent or factor that causes malformation of embryo
• H2O & fat content
 Calculate some meds by body weight
 OA have special considerations
 OA H2O in body
 Water soluble drugs won’t distribute as well
 Older pt’s drug may be toxic
 OA  % of body fat
 Causes longer duration of drug action
• Results in slower drug distribution
 Lower body wt  greater concentration of meds in body
 OA may get lower dose than younger adults
• Avoid toxicity
• Protein binding
 Can be agonist or antagonist
 Agonist produces same type of response as physiologic or endogenous substance
 Antagonist inhibits cell function by occupying receptor sites
 Drugs that bind to proteins
 Most meds do bind to proteins
 Albumin
 Binds to a lot of meds & makes them inactive
 OA c low albumin level
 Given less of drug b/c there more free “active drug”
 Can have toxic effect o Metabolism
 Meds changed into less active or inactive form
• Called “biotransformation”
• Necessary process to breakdown or detoxify drug
 Mostly takes place in liver
 Lungs, kidneys, blood, & intestines contribute to process
 Compromised organs may have problems breaking down drug
• Results in toxicity or overdose situation
• Build up of drugs in blood
 Know toxic symptoms o Excretion
 How meds exit
 Where drug exits is determined by chemical makeup of meds.
 Kidneys are main excretion organ
 2 organs
• Bowel
• Lungs
• Exocrine glands
 Sweat glands
 Breast
 Deep breathing/coughing can help excrete meds
• Another reason for general anesthesia pts to DB & C
 Good hygiene of skin is important b/c meds come out of skin
• Don’t want meds to stay there & damage skin
 Breast milk
• May contain meds excreted by mom
• May have to suspend breast feeding
 GI tract
• Exit of meds metabolized by liver
• Decreased mobility can affect
 Effect of peristalsis
 Can make meds stay in body longer
 Results in OD or toxicity

Route Advantages Disadvantages
Oral -Most convenient
-Usually least expensive
-Safe, does not break skin barrier
-Administration usually does not cause stress
-Some new oral medications are designed to rapidly dissolve on the tongue, allowing for faster absorption & action -Inappropriate for pts c nausea or vomiting
-Drug may have unpleasant odor or taste
-Inappropriate when gastrointestinal tract has reduced motility
-Cannot be used before certain diagnostic tests or surgical procedures
-Drug may discolor teeth, harm tooth enamel
-Drug may irritate gastric mucosa
-Drug can be aspirated by seriously ill pts
Sublingual -Same as for oral, plus:
-Drug can be administered for local effect
-More potent than oral route b/c drug directly enters blood & bypasses liver -If swallowed, drug may be inactivated by gastric juice
-Drug must remain under tongue until dissolved & absorbed. May cause stinging or irritation of mucous membranes
-Drug is rapidly absorbed into bloodstream
Buccal (cheek) -Same as for sublingual Same as sublingual
Rectal -Can be used when drug has objectionable taste or odor
-Drug released at slow, steady rate
-Provides local therapeutic effect -Dose absorbed is unpredictable
-May be perceived as unpleasant by pt
-Limited use
Vaginal -Provides local effect -May be messy & may soil clothes
Topical -Few side effects
-Prolonged systemic effect -Drug can enter body through abrasions & cause systemic effects
-Leaves residue on skin that may soil clothes
Transdermal -Few side effects
-Avoids GI absorption problems
-Onset of drug action faster than oral
Subcutaneous
-Involves sterile technique b/c breaks skin barrier
-More expensive than oral
-Can administer only small volume
-Slower than IM administration
-Some drugs can irritate tissues & cause pain
-Can produce anxiety
Intramuscular -Can administer larger volume than subcutaneous
-Drug is rapidly absorbed -Can produce anxiety
Intradermal -Absorption is slow (advantage in testing for allergies) -Amount of drug administered must be small
-Breaks skin barrier
Intravenous -Rapid effect -Limited to highly soluble drugs
-Drug distribution inhibited by poor circulation
Inhalation -Introduces drug throughout respiratory tract
-Rapid localized relief
-Drug can be administered to unconscious pt -Drug intended for localized effect can have systemic effect
-Of use only for respiratory system

Types of drug preparation pg 831 Kozier
Type Description
Aerosol A liquid, powder, or foam deposited in a thin layer on the skin by air pressure
Aqueous One or more drugs dissolved in water
Aqueous suspension One or more drugs finely divided in a liquid such as water
Caplet A solid form, shaped like a capsule, coated & easily swallowed
Capsule A gelatinous container to hold a drug in powder, liquid, or oil form
Cream A nongreasy, semisolid preparation used on the skin
Elixir A sweetened & aromatic solution of alcohol used as a vehicle for medicinal agents
Extract A concentrated form of a drug made from vegetables or animals
Gel or jelly A clear or transparent semisolid that liquefies when applied to the skin
Liniment A medication mixed c alcohol, oil, or soapy emollient & applied to the skin
Lotion A medication in a liquid suspension applied to the skin
Lozenge (troche) A flat, round, or oval preparation that dissolves & releases a drug when held in the mouth.
Ointment (salve, unction) A semisolid preparation of one or more drugs used for application to the skin & mucous membranes
Paste A preparation like an ointment, but thicker & stiff, that penetrates the skin less than an ointment
Pill One or more drugs mixed c a cohesive material, in oval, round, or flattened shapes
Powder A finely ground drug or drugs; some are used internally, others externally
Suppository One or several drugs mixed c a firm base such as gelatin & shaped for insertion into the body (e.g. rectum); the base dissolves gradually at body temp, releasing the drug
Syrup An aqueous solution of sugar often used to disguise unpleasant-tasting drugs
Tablet A powdered drug compressed into a hard small disc; some are readily broken along a scored line; others are enteric coated to prevent them from dissolving in the stomach
Tincture An alcoholic or water-and-alcohol solution prepared from drugs derived from plants
Transdermal patch A semipermeable membrane shaped in the form a disc or patch that contains a drug to be absorbed through the skin over a long period of time

o Pharmacodynamics
 Protect cells from other agents
 Promote cell function
 Accelerate or slow down cell processes
 Replace substances that are missing in body
• Ex: insulin or synthetic thyroid hormone
 Rxns
• Every pt reacts differently
• Side effects are predictable
• Adverse effects are unpredictable
• Therapeutic effects are expected
 Types of rxns to drugs
• Therapeutic effects
 Expected effects
 What you want to happen
 Important that RN know WHY pt getting particular drug
 To see if is working
• Side effects
 Unintended 2 effects of medicine
 Predictable effect
 Some pts will have it, some not
 Some harmful, some not
 Some side effects can be tolerated or ameliorated
 Dry mouth
 May stop use if pt can’t tolerate taking drug or side effects outweigh benefits of med
• Adverse effects
 Generally severe rxn to med
 Generally unexpected
 Rare
 May stop use of drug
 Example
 Seizure
 Unconsciousness
 MI
• Toxic effects
 Build up of med in tissues due to impaired metabolism or excretion
 Build up due to overdose
• Idiosyncratic rxn
 When pt over reacts or under reacts to med
 Sometimes opposite rxn than anticipated/wanted
 Benadryl in young kids
 Makes them hyper instead of sedated
• Allergic rxns
 Immunologic response
 Mild or severe
 Symptoms vary
 Ask every pt if have allergies
 Look on drug chart or Hx
 If chart does not match drug card, validate c pt or SO
 Always ask pt if allergic before giving pt med
 Must have initial contact c drug before allergic rxtn will manifest
 Rxn may get worse over time
 Antibiotics have high incidence of allergic rxn
 Mild
 Urticaria
 Raised irregularly shaped skin lesions called wheals
 Hives
 Rash
 Small raised vesicles
 Often generalized
 Often red
 Pruritus
 Itching of skin
• Occurs c most rashes
• Can be c or s rash
 Rhinitis
 Inflammation of mucous membranes of nose
 Swelling, clear discharge
 Lacrimal tearing
 Excessive tearing in eyes
 Moderate
 N/V
 Don’t have to be allergic
• Could just be side effect
• Listen to pt
 Usually result of allergic rxn in brain center that controls this stimulus
 Not GI thing
 Diarrhea
 Large intestine mucous is irritated
 Wheezing/dyspnea
 Very serious
• Needs immediate action
 SOB
• Due to swelling & fluids in respiratory passage
 Angioedema
 Rapid swelling of skin, mucosa & submucosal tissues
• Due to increased permeability of blood capillaries
• Mediated by allergy
• Been reported as side effect of some medications
 Can cause CHF
 Severe
 Anaphylactic rxns
 Could stop breathing
 Edema of pharynx, larynx, & constriction of bronchiolar muscles
 Severe wheezing or SOB
 Hypotension
 Emergency
• Can be fatal
• Should wear ID bracelets or tags indicating
 Very serious
 Use epinephrine
• “Epi-pen”
 Drug interactions
• Administration of one drug changes effect of another drug or both drugs
• Can increase or decrease effects of med
 Potentiating
 Synergistic
• Can inhibit responses
 RN responsibility to find out what pt taking
 Effects can sometimes be beneficial
• Iatrogenic disease
 Disease caused unintentionally by medical therapy
 Therapeutic procedure causes diseases or conditions
 Hepatic failure
 Renal problems
 Fetal malformation
 Caused by medical interventions
 Not on purpose
• Action of drug on body
 Onset of Action
 Time after administration when body initially responds to drug
 Peak Plasma Level
 Want to maintain PPL
 Highest plasma level achieved by 1 dose when elimination rate of drug equals absorption rate
 Pt must get another dose or concentration levels will decrease
 Reason why important to give drug on time
 Plateau
 Maintained concentration of drug in plasma during series of scheduled doses
 Want plateau
• Have window of 30 min before or after
• Wait beyond window
• Will not keep therapeutic level in blood stream
• Could make it take longer to get rid of infection
 Half-life
 Elimination half-life
 Time required for elimination process to reduce concentration of drug to 1/2 of initial dose
 Will help MD figure out when next dose should be given

Psychotropic medications African American pts experienced faster therapeutic responses to tricyclic antidepressants, higher serum concentrations, & more adverse rxns than Caucasian pts.
African American pts may require lower dose of lithium than white pts.
Antihypertensive medications Studies have shown that certain angiotensin-converting enzyme (ACE) inhibitors (e.g. captopril & enalapril) & angiotensin II receptor antagonist (e.g. losartan) were found to be less effective in African Americans than in whites.
Thiazide diuretics appear to be more effective antihypertensives in African Americans than in whites.
Beta blockers can vary among ethnic groups. African Americans may require higher dosages than whites, & Asians usually require lower doses than whites.
Implications for nursing interventions Remember that there may be differences in medication responses among different ethnic groups & differences within ethnic groups. Ask about health beliefs, values, & customs/practices. Conduct cultural assessment c each pt. Learn about drugs that are likely to elicit varied responses in people from different ethnic groups, as well as potential for adverse effects. Ask pt direct, specific questions to reveal presence or absence of potential adverse effects of medications. Monitor pt & document findings carefully as it may be possible to maintain therapeutic benefit at lower dosage of given drug. Keep cultural context in mind when planning education for pts & families.

 Factors affecting med actions (9)
• Developmental age & lifespan considerations
 Infants
 Smaller doses b/c immature organs
 Immature liver & kidneys mainly
 Body size
 OA
 Different or adjusted dosing b/c excreted differently in OA
 Due to
• Lower metabolism
• Lower respiratory rate
• Organ impairment
• Lower H20 content
• Higher fat content
 Pregnancy &/or breast feeding
 Hormones
 Don’t want to hurt fetus
• Gender
 Men & women respond differently R/T fat, hormones, & hydration
 Most meds tested on men
 Don’t really have empirical data on how meds affect women
• Cultural, ethnic, & genetic
 Some races act differently to drugs due to
 Genetics
 Diet
 Nutrients can affect drug rxns
 Check drug book
 Compliance/cultural practices
 Can be using herbal remedies
• Diet
 Nutrients can affect actions of med
 Vitamin K can counteract Coumadin
 Some foods counteract effect of med
 May keep from being absorbed
 Check drug book to see if diet restriction c drug before giving med
• Environment
 Temperature
 Cold  slower drug action
 Heat  faster drug action
 Sunlight can affect drugs
 Setting
 Quiet if giving sedative
 Noise
 Environment noise
 People coming in to do procedures
 People in room
 Some drugs must be put in fridge
 Some IV solution can’t be exposed to light
• Psychological
 Meds may or may not relieve pain b/c of psychological effects
 Due to personal or 2 experience c med
 Placebos
 Inert substance
 Can be given IV, pill, or IM
 Helps to determine if drugs work in experimental condition
 Pt expectation of drug effect must be considered
 Use could break trust
 Unethical
 RN doesn’t have to give it even if MD orders it
 Can only be given c doctor’s orders
• Illness & disease
 Can affect absorption, metabolism, excretion of drug
 Some pts can't take meds certain ways
 Diseases that affect circulation, liver, heart, & kidney will also affect efficacy of med
 Disease can affect how med is given
 Can’t swallow or burn pt.
 Dosage may be affected
• Timing of administration
 2 hrs before or after meal  empty stomach
 Sometimes need to give c meal or snack
 Consider sleep/wake cycle
 Very important to give at right time
 Can effect drug action & speed
 Sometimes give after meal
 Timing of administration of meds can be due to when body processes occur
 Some meds must be given in am
 Some meds must be given in pm
 Lipator b/c liver makes cholesterol in pm

6 Roles & responsibilities o Prescriber
 Examples
• Doctor
• ANP
 Advanced nurse practitioner
• PA
 Physician assistant
• Dentist
 Orders drug
 Writes legal Rx on legal Rx pad
 Written order or VO
 Nurse can write down VO
• Given in person or on phone (PO)
• Doctor needs to sign it within 24hrs
 VO Dr. Smith/ S. Randol RN
• Know policy in hospital
 Be sure that written orders are clear
 Students CANNOT take VO or PO
 Construction of Dr orders
• Date/time
• Drug
• Dosage
 4mg/kg, 20mg
• Route
 Oral, IM etc
• Time frame
 Q4h, bid etc
 Types of orders
• Standing or routine orders
 Order that may or may not have termination date
 May be carried out indefinitely until an order is written to cancel it
 May be carried out for specified number of days
 Demerol 1100 mg IM q4h x 5 days
 Some agencies standing orders automatically canceled after specified number of days & must be reordered
• Prn orders
 “As needed”
 Permits RN to give med when, in RN’s judgment pt requires it
 RN must use good judgment about when med needed & when it can be safely administered
 HA
 Ibuprofen 200 mg i-ii q3-4h prn
• i-ii is banned abbreviation
• Single dose orders
 For med to be given once at specified time
 Valium 10 mg po at 0900
• Stat orders
 Indicates that med to be given immediately & only once
 Give Lidocaine IV 50 mg bolus STAT o Pharmacist
 Responsible for filling Rx accurately
 Prepares & distributes
 Makes sure Rx is valid
• Correct ranges
• Dose
• Route
• Time
 Offers information about med
 Assesses home meds o Nurse
 Needs to make sure everything correct
 Spends most time c pt
 Knows pt on min. to min. basis
 Requires set of knowledge & skills to keep pt safe
 Uses clinical reasoning to determine if RN will follow Rx for meds
• Can hold meds if status of pt requires
 Checks meds 3 times before giving it
 Prescriber, pharmacist & nurse work together to ensure pt gets right medical therapy o RN is accountable for knowing
 What med is prescribed
 Why prescribed for particular pt
 Therapeutic/Non-therapeutic effects
 Usual dose ranges
 Usual route
 Any nursing considerations
• Effects to VS
• Any pre-med VS or other considerations that make giving med not correct
 Pulse, BP, respiratory, temperature
 C food
 Time of day
 Pts level of knowledge
• May have to do some teaching or answer questions o RN is accountable for administration
 “6 Rights”
 Check these 3 times prior to administering
• Right Pt
• Right drug
• Right dose
• Right route
• Right time
• Right documentation
 Very important
 Document immediately o RN accountable for these after administering
 Monitoring for effectiveness
 Adverse, side, toxic, allergic effects
 Teaching pt/family about med
 Conditions can change status of an order
 Usually surgery will cancel all pre-op orders
 Look/sound alike drugs (Moodle) o Nursing diagnosis
 High Risk for Injury
• Trauma, falls
• Meds that make PT drowsy
• Poisoning R/T cognitive deficit
 High Risk for ineffective management of therapeutic regimen
• Discharge planning steps
• Due to complicated regimen
• See/use this a lot
 Noncompliance
• Want to do right thing but unable to
 Too weak or sick
• Not taking meds like supposed to
 Want to comply but something stopping them
• This Dx NOT about pt being defiant or stubborn
 About not knowing or understanding

Administering meds
7 Medication administration o Primary goal is SAFETY o Must follow appropriate procedures o Protects pt & nurse o Steps to medication administration
 Identification
• Correct pt
• Correct pts medication
• Correct chart
 Chart
• Check
 Name
 Room #
 Allergy sticker
 Not allergic
 NKA
 NKDA
 NKFA
• Make sure every page has your pt’s correct name/info
• MAR
 Medication administration record
 Tells us what med to give & @ what time
 24 hr record
 Gathering meds
• Check meds 3 times
 At medicine cart
 In pt’s room
 As giving meds to pt
 Validate information
• Identify bin c pt’s name in medication room
• Only give meds for one pt a time!!!
 “Pouring” meds
 Unlock bin
 Have MAR c you & meds
 ID all meds c correct time on them
 Check name & dose of med c actual pill
 Check pill to ensure correct name/color/expiration dates
 Gather all meds in paper cup c wrappers still on & take in pt’s room
• Check room number before entering
 Ask pt their name WHILE looking at name band
• Scan bracelets & meds SEPARATELY
• Also check for allergy bands on pts
• Can also perform nursing assessments when identifying pt
 Vital signs
 Meds c food
 Open if everything is ok
• Computer tells if wrong med/dose if scanning meds
 Research meds
• Never give unfamiliar meds
• Know
 Why pt is receiving med
 Drug classification
 Contraindications
 Usual dose range
 Side effects
 Nursing considerations
 Allergic rxns
• Nursing implications of meds
• Inform Pt o Administer drug to pt using “6 Rights”
 Right pt
 Right med
 Right dose
 Right time
 Right route
 Right documentation
• Chart to prevent overdoses
• Know different ways to document
• Never mark off med before you give it
 Wait 30-45 minutes to see if med is effective
• Intended/adverse reaction
• Pt vomiting or have rash, etc? o Objectives
 Administer meds safely
 ID potential sources of error
 Administer meds following 6 rights o Oral meds
 NPO
• Nothing by mouth
 PO
• By mouth
 Unit dose system
• 1 pill, 1 pack, etc
• Bin c 24 hour meds re-supplied by pharmacy
• Be aware of how to open
 Bingo cards or multi-dose packages
 Check to see if meds are oral, chewable, sublingual, buccal
• Oral med administration advantages
 Most common
 Least expensive
 Most convenient
 Safest route for most pts
• Disadvantages include
 Unpleasant taste
 Irritation of gastric mucosa
 Irregular absorption from GI tract
 Slow absorption
 Possible harm to pts teeth
• Sublingual administration
 Drug placed under tongue to dissolve
 Drug absorbed into blood vessels under tongue
 Should not be swallowed
 Can be destroyed by stomach acids
 Always use this med LAST
 Nitroglycerin
• Buccal administration
 Med held in mouth against mucous membranes of cheek until drug dissolves
 Acts locally (in mouth) or systematically (swallowed in saliva)
 Absorbed into tongue (vascular)
• Crush meds for pts c dysphagia
• Wipe pill crusher clean & wear gloves b/c some drugs are carcinogenic, teratogenic
• Enteric coated pills can’t be crushed
 Meant to be absorbed in intestines
• Can only break or cut scored tablets if necessary to obtain correct dose
 Must discard other half
 Have witness if narcotic
 If meds are not scored, pharmacy can cut them for you c more precise devices
• Time-released meds can’t be crushed b/c would all be dissolved at once
• If pt has dysphagia & cannot crush/open pills
 Call pharmacy
 Call MD
 Circle it on MAR if held o Liquid medications
 Most come in multi-dose bottles
 Take whole bottle into room (barcode)
 Look at strength of med
• 10 mg/mL
• Need correct one to ensure pt doesn’t OD
 Measure on flat surface & read meniscus
• Lowest point in curve
• This is especially important in children who are given small doses
 If cough syrup, do not follow c glass of H20
• B/c syrup is designed to coat
• Always give this med last
 Make sure pt is in correct position when administering meds
 Sit pt up if oral meds
• Prevent aspiration
 Some pts need help holding head up
 Ask pts how many meds they can take at one time
 Don’t leave meds in room c pt/pts family
• Witness pt taking meds
• Look in mouth to be sure they took all of them
• Some pts harbor meds & to commit suicide later
• Older pts just don’t take meds sometimes
 Leave pts sitting upright for 30 min after giving meds o Topical medications
 Include ointments, eye/ear drops, patches
 Eye drop administration
• Administered in conjuncitval sac to remove secretions or other foreign bodies
• OU
 Both eyes
• OD
 Right eye
• OS
 Left eye
• Check for word “ophthalmic” on bottle & compare c MAR
• ID pt
• Explain to pt what is happening, why, & how they can cooperate
• Wash hands & wear gloves
• Prepare pt
 Position c head tilted back in comfortable position
• Clean eyelid/lashes
• Put on new gloves
• Compress lacrimal apparatus so med won’t exit through nose
• Pull bottom eyelid down c another finger to expose conjuncitval sac
• Place drop in middle of conjuncitval sac by bottom eyelid
• Have pt close eye & roll around
 Don’t have to compress lacrimal sac for ophthalmic ointments o Ear drop administration
 “Otic”
 Wear gloves
 Position pt on side c head turned
 Ear getting drops facing up
 Examine ear 1st then clean pinna & meatus of ear canal
 Test drops to see how fast they drop out
 Drop right above ear canal
• Adults & child over 3
 Pull pinna up & back
• Child under 3 & infants
 Pull pinna down & back
 Put 4x4 over meatus keeping head turned for 5-10 min per ear o Nose drop administration
 Usually administered to
• Shrink swollen mucous membranes (astringent effect)
• Loosen secretions & facilitate drainage
• Treat infections of nasal cavity or sinuses
 Place pt supine position
 Place pillow below neck so head can be hyperextended back
 Drops to be placed in sinus, position head all way back & tilted to side
 Remain in this position at least 1 minute
 Pt sits upright for nasal mists o Meter dose inhalers
 MDI
 Handheld nebulizers
 For respiratory illnesses
 Shake every time is used
 Check for proper placement
• In mouth
• Two to three inches from mouth
 Discuss inhalers
 Inhale, exhale, then inhale c med
 Tell pt to hold breath 10 sec after med inhaled
 Exhale slowly through pursed lips
 Wait 1 minute between puffs
 If med is bronchiodilator, always use 1st
 Clean off mouth piece
 Rinse pt’s mouth if steroid
 Nebulizers deliver most meds administered through inhalation
• Deliver fine spray of medication or moisture to pt
• Smaller droplets can be inhaled deeper
• 2 kinds
 Atomization
 Produces large droplets
 Aerosolization
 Droplets suspended in gases o Transdermal medications
 Gloves needed b/c meds designed to be absorbed through skin
• Heart meds
• BP meds
• Nicotine patches, etc.
 Locate & remove old patch
 Clean area
 Dispose in biohazard
 Identify area to place patch
• MD’s orders
• Med instruction
• Temperature/vascularity can influence absorption
• Sometimes need to clip or shave area
• Clean area & let dry on its own o Topical dermal agents
 Antibiotic ointments, etc.
 Some meds need to be covered c dressings

Medication dosage calculations
8 Abbreviations & med dosage calculations o 70% of doctor's mistakes are caught by nurse o 98% of nurse's mistakes reach pt o Trust by verifying o Objectives
 Understanding of
• Abbreviations
• Symbols
• Systems of measurement
 Application of
• Medication equivalences
• Table of conversion factors
• Dimension analysis method for problem solving o Abbreviations
 Too many to know
 Some based in Latin
 Many are confused
 Milligram mg
 Microgram mcg
 Teaspoon tsp
 Tablespoon tbsp
 ½ ss
 1 ½ iss
 Every day qd
 4 times daily qid
 Twice daily bid
 3 times daily tid
 Gram g, gm, G, Gm
 Grain gr o Symbols
• Use of roman numerals
 1, i, I, i
 One o Systems of measurement
 Apothecary
• Oldest system
• Measurements such as minim, dram, ounce, grain
 Household
• "Handy" system
• Measurements such as teaspoon, tablespoon, ounce
 Metric
• Newest, most accurate system
• Measurements such as grams, milligrams, micrograms, kilograms, milliliters, & liters o Problems for nurses
 Making interconversions between systems
 Inaccuracy of 2 of 3 systems
• Apothecary
• Household
 Interpretation of medication order
 Reliance on arithmetic skills
 Physicians handwriting o Medication equivalencies
 Pharmacy supplies drug in specified concentration or amount/volume
 Supplied Equivalency
 10mg tablets 1 tab = 10mg
 gr 1/150 cap 1 cap = 1/150gr
 125mg per 5ml 5ml = 125mg
 U-100 insulin 1ml = 100 units
 400mcg/1L of D5W 1000ml = 400mcg
 Concentration is stated on container label o Considerations in calculations
 4 requirements for problem solving
• Identification of necessary information
• Formatting of information as fractions
• Understanding of prescribers intent
• Interpretation of drug label information
 ID of necessary information
• Sample Order
 Lanoxin, 0.25mg po daily
• What necessary info does nurse need to know in order to comply c order:
 Instruction implied in med order
 Form of med supplied by pharmacist
 Formatting of info as fractions
• Every item in calculation has numerator & denominator
• The numerator is equal or equivalent to denominator
• All items in calculations have number & label
 Understanding prescribers intent
• Does med order specify an amount per dose or an amount per day
• Med order must be one or other
• Rule of thumb
 Doesn't say per day means its per dose
 Interpretation of drug label info
• What info does drug label specify that is needed in calculation
 Label identifies form of med supplied by pharmacist
 Label identifies concentration of drug o Sample Problem
 How many tablets of lorazepam (Ativan) would you administer if physician orders 2mg to be given orally once daily?
 Med label reads
• Larazepam 0.5mg tabs
 Nurse needs to know
• Number of tabs
 Formatted as fraction
• Tabs/dose
 Physicians intent
• Amount/dose
 Drug label equivalency
• One tab = 0.5mg o Dimensional analysis
 Step 1
• Identify desired answer labels as fraction on left side of equation
 Tabs
 Dose
 Step 2
• Identify starting factor c desired numerator label on right side
 Tabs/dose = 1 tab/0.5mg
 Step 3
• Establish a "unit path" of fractional factors that are sequentially cancelled until desired denominator label appears
 Tabs = 1 tab x 2mg
 Dose 0.5mg dose
 Step 4
• Solve problem using single line of computation & simple arithmetic
 Tabs = 1 tab x 2mg = 4 tabs
 Dose 0.5mg dose dose o Sample problem
 Med order
• Lanoxin .25 mg po daily
 Begin c fraction of what you seek to find
• Tabs =
• Day =
 Identify starting factor c desired numerator label on right side
• Tabs = 1 tab X .25 mg = 1 tab
• Day = .25 mg X Day = day o Sample problem
 How many tabs of Amytal will you administer if the physician orders 1/6 gr & the pharmacy supplies it as 1/3 gr scored tabs?
 Tabs =1 tab x1/6 gr =0.16667 tab = 0.500005
 Dose 1/3 gr 1 dose 0.33333 dose
 0.500005 = .5 tabs/dose o Sample problem
 Physician orders gr X (ten grains) or Tylenol (acetaminophen) elixir p.o. for elevated temperature. The elixir contains 120mg per 5cc. How many cc will you administer?
• cc = 5 cc x 60 mg x 10 gr = 25cc
• Dose = 120 mg x 1 gr x dose = dose o Sample problem
 The order is for Fiorinal 30mg po hs. On hand are 1/8 gr capsules
 How many capsules will you administer?
• caps = 1 cap x l gr x 30mg = 4 caps
• dose 1/8gr 60mg dose dose o Sample problem
 Lorazapam (Ativan) 2 mg po now.
 Label reads Lorazepam .5 mg tabs
• Tablets=1 tablet x 2 mg=4 tablets
• Dose 0.5 mg dose dose o Multiple daily dosing
 When order reads:
• ASA gr 10 po q4h
• 10 mg po TID
• 1 gm divided equally ql2h
• Insulin 10 units sc AC breakfat & AC supper.
 ac before meal
 Literal translations of dosing time instructions do not work for calculations
• Literal translation Calculation
• q3h (every 3 hours) 8 doses/day
• q4h (every 4 hours) 6 doses/day
• q6h (every 6 hours) 4 doses/day
• q8h (every 8 hours) 3 doses/day
• ql2h (every 12 hours) 2 doses/day
• q24h (every 24 hours) 1 dose/day
• qd (once daily) 1 dose/day
• bid (two times a day) 2 doses/day
• tid (three times a day) 3 doses/day
• qid (four times a day) 4 doses/day o Sample problem
 Order is for Phenobarbital elixir gr ss po q8h. The label on the vial reads: 10mg/ml.
 How many ml will you give per day?
• ml = ml x 60mg x 1/2 gr x 3 doses = 9ml
• Day 10mg 1 gr dose day day o Sample problem
 Doctor orders theophylline syrup, 2 tsp ql2h. Meds concentration is 80mg/20ml.
 How many mg will you give per dose?
• mg = 80mg x 5ml x 2 tsp = 40 mg
• dose 20 ml tsp dose dose o Sample problem
 The order is to give 0.75g of polycillin (ampicillin) oral suspension qid.
 The med is labeled 250 mg/5 ml. How many (fluid) ounces will you give each day?
• oz = 1 oz x 5ml x 1000mg x 0.75g x 4 doses = 2oz
• Day 30ml 250mg 1g dose day day o Weight-based med order
 Order in which amt of med to be given is based on how much pt weighs in kilograms
• 8 mg/kg/day
• 250,000 units/kg/dose
• 10 mg/kg ql2h
• 4 mcg/kg/min
• 10 mg/kg/d
• 25 mg/kg TID
 Utilizes "triple fraction"
• 8mg/kg/day
 8 mg is numerator
• kg/day are both denominators
 8mg
 kg- day
 Unique conversion factor needed for weight-based calculations
 1 kg = 2.2 lbs o Sample problem
 The recommended dose of Garamycin (gentamicin) is 7.5mg/kg/d divided equally q8h. Determine the total daily dose for a 9lb 8oz infant.
• Mg = 7.5mg x 1 kg x 9.5lbs = 32.38mg
• Day kg-day 2.21 lbs 1 day o Sample problem
 The order is for digoxin (Lanoxin), 0.04mg/kg/d, divided q8h.
 The label reads: 0.25mg per scored lab.
 What will you administer per dose to a 62lb pt?
• Tabs = 1 tab x 0.04mg x 1 kg x 62lbs x 1 day = 1.5 tabs
• Dose 0.25mg kg-day 2.2 lbs 1 3 doses dose o Medication reconstitution problems
 Each problem contains 2 sets of info
• Mixing instructions
• Medication order o Sample Problem
 The order is to give 1.25 gm of Cefobid IM ql2h.
 Directions on 2 gm vial state:
 Reconstitute c 5.6ml of sterile H2O to yield withdrawal volume of 6ml c concentration of 333 mg/ml
 How many ml will you give?
• ml = 1 ml x l 000mg x 1.25g = 3.75 ml
• Dose 333mg 1 g dose dose o Sample problem
 Order is to give Omnipen (ampicillen) 350mg IM q6h.
 Directions on 250ml vial state:
 Add 0.9 cc of sterile H2O to produce a concentration of 125mg/0.5 ml.
 How many ml will you give?
• ml = 0.5ml x 350mg x 4 doses = 5.6ml
• dose 125 mg dose day day o Insulin problems
 Concentration of injectable insulin is stated in special way
 100 units per ml (cc) o Sample problem
 Order reads regular insulin subcutaneous, 45 units AC breakfast & 12 units AC supper.
 How many ml of insulin will you inject each morning?
• ml/dose =1 ml/100U x 45U/dose = 0.45ml/dose
 Note: If there is any time you get more than 1 cc of insulin then you are wrong
• Should never be over 1 cc o Sample problem
 The order reads: regular insulin (Humulin U-100) sc, 45 U AC breakfast & 12 AC supper.
 How many ml of insulin will you inject each day?
 ml/day = l ml/I OOU x 57U/day = 0.57m1/day o IV fluids order
 Order is for volume of fluid per unit of time
• 1000 cc of D5W q8h
• 50 cc/hr
• 250 cc to run in over 3 hours
• 10 drops/min
 No med is involved; only IV fluids
• Ex. Order. D5W 1000cc q8h. The fluids will flow continuously at a constant rate (drops/min or cc/min) such that pt will receive total 1000cc in 8hrs.
 Flow rate is controlled by drop factor of IV tubing
• Macrodrop = 10, 15, 20, 25, or 30 gtts/ml (blood)
• Microdrop = always 60 gtts/ml
 Used c peds & c certain drugs
 What does nurse need to know to comply c order?
• Rate or volume per unit of time at which to allow fluids to flow
• Drops per min (gtts/min)
• mls per min (cc/min)
• mls per hour (cc/hr) o Sample problem
 Order is to give 1000cc of D5W ½ NS to run in q6h.
 The drop factor of the IV tubing is 20 drops per ml.
 How fast will you run the IV fluids in gtts/min?
 gtts = 20gtts x 1000ml x 1 hr = 55.55gtts = 56gtts
 min 1 ml 6 h 60 min min min o Sample problem
 Physician orders 3U of blood (each unit = 500m1) to run in over 4hrs.
 Using a drop factor of 10gtts/cc.
 How fast will you run the N in qtts/min?
 qtts/min =10gtts/cc x 1500cc/4h x lb/60min = 62.5qtts/min = 63qtts/min o Intravenous meds
 Meds, mixed c IV fluids, are administered intravenously in 2 ways.
• Intermittently flowing administration:
 "Piggy-backed" into another IV fluid line
 The order is to administer Mandol (cephamandole) 1 gm 1VPB g6h...over 15min
 Continuous flowing administration
• The order is for an infusion of theophylline at 25mg/hr d
• Drug is dissolved as 500mg in 500cc of fluid... o Sample problem
 Order is to give Aldomet 250mg q6h IVPB:
 The drug is diluted as 250mg in 100ml of D5W.
 Using a drop factor of 60gtts/ml
 How fast should you run the IV in gtts/min in order to administer the drug over 1 h?
 gtts = 60gtts x 100ml x 250mg x 1 h = 100 gtts
 min 1 ml 250mg 1 h 60 min min o Sample problem
 2 gm Ancef IVPB infused over 30 min
 2gms of drug dissolved in 50 ml of D5W
 How fast will run IV in gtts/min using microdrip IV drop factor?
 gtts = 60 gtts X 50 ml X 2 gm = 100 gtts
 min = ml 2 gm 30 min = min o Sample continuous IV problem
 The order is to infuse Isuprel (isoproterenol) at rate of 3 mcg/min
 The concentration of Isuprel supplied by pharmacy is 2 mg dissolved in 250 ml of D5W
 Using drop factor of 60 gtts/cc, find rate of infusion in gtts/min
 gtts = 60gtts x 250 ml x 1 mg x 3 mcg = 22.5 gtts
 min 1 ml 2 mg 1000 mcg 1 min min o Sample continuous IV problem
 Order for continous heparin infusion @ 50units/kg q4h
 Heparin available as 25,000 units/L of D5W.
 Using 20 gtts/ml
 Calculate flow rate in gtts/min for 80 kg pt.
 gtts = 20 gtts X 1000ml X 50 units X 80 kg X 1 hr = 13 gtts
 min ml 25000units kg/4hrs 1 60 min min o Sample Dopamine
 Ordered at rate of 3 mcg/kg/min continuous infusion
 Concentration is 400 mg in 500 ml of IV fluid
 Calculate frow rate in ml/hr for 210 lb pt.
 ml = 500 ml x 1 mg x 3 mcg x 1 kg x 210 lb x 60 min = 21.4 ml
 hr 400 mg 1000 mcg kg/min 2.2 lbs 1 1 hr hr o Metabolism
 Must be metabolized to be secreted.
 Occurs in the liver.
 Called biotransformation.
 Lungs, kidneys & blood contribute to metabolism. o Excretion
 Exit the body – via kidneys, liver, bowels, lungs & exocrine glands.
 Chemical makeup of drug – determines this method.
 GI tract is method of excretion of meds absorbed in the liver.

Topic VI: Mobility/Immobility
9 Mobility/Immobility o Mobility is essential to life
 Not being able to move effects every organ in every system in body
• Mobility keeps organs & systems in working order o Mobility
 Moving around freely o Immobility
 Not being able to move about in purposeful way
• Coma
• Paralyzed
• Pt to weak to move o Decreased mobility
 2 broken legs o Impaired mobility
 Pt can move c limitations
• Bedrest
 Can exercise, eat, etc.
 BR usually ordered by the doctor
• Pt is in bed
 Complete (strict) BR
• CBR or strict BR
• Can't get out of bed for any reason
• Can move them & perform ROM)
 BR c bathroom privileges (BR c BRP)
 BR c bed side commode (BR c BSC)
 BR & up for meals o Immobile
 Pt can not move
 Paralyzed o Decreased mobility o BR ordered to
 Decrease O2 needs & demands by reducing activity
 Allow pt to rest & regain strength
 Prevent injury & reduce pain o Conditions requiring BR:
 Cardiovascular conditions
• Acute MI
• CHF
 Cardiomyopathies
• Inflammation of myocardial tissues
 Neurological conditions
• Head injuries
• Spinal cord trauma
• Degenerative neurological condition
• Inflammatory diseases of nervous system
 Guillain-Barre syndrome
• Bleeding aneurysms
 Musculoskeletal conditions
• Multiple fractures of LE
• Surgical reattachment of traumatically amputated extremity
 Pulmonary conditions
• End stage chronic lung diseases
 Other conditions
• Terminal phases of cancer
• Pts awaiting major organ transplants
• Morbid obesity o Pt must accept BR
 Keep from fighting & increasing oxygen needs
 Must go in pt's room
 Help c mobilizing pt o Factors affecting mobility
 Physical health
• Muscles, bones, joints
• Postural abnormalitites
 Scoliosis
 Foot drop
• Oxygenation & perfusion
 Must have adequate O2 to keep muscles moving
• Nervous system
 Must be intact to be able to control movements
 Environment
 Heat/cold
 Altitude
 Barriers
 Bed rails
 Slippery floors
 Furniture in way
 Stairs
 Prescribed Txs
• BR
• Restraints
• Medications
• Sedation
• IVs
• Catheters o Problems from decreased mobility
 Can be prevented by nurses
• Pneumonia
• Pressure sores
• Table pg 1126
 Respiratory System
• Atelectasis
 Pooling of secretions
 Become thick & stagnant leading to infection & pneumonia & atelectasis
 Matter of life & death
 Pneumonia & atelectasis are very preventable by movement
 Turning every 1-2 hours minimum
 Shallow respirations because they can't fully expand their lungs –
 Decreased air exchange (oxygen)
 Teach coughing & deep breathing.
 Mobility is the primary thing to prevent atelectasis
• Infection
 Cardiovascular System
• Valsalva maneuver
 Take deep breath & bear down
 Puts pressure in thorax
 Any activity that causes you to hold your breath & strain
 Putting pt on bedpan
 BM puts increased pressure on heart
 Can lead to dysrhythmias
 Heart can slow down/stop
 Low LOC
 Can cause pt to black out
• Orthostatic hypotension
 Heart becomes ineffective pump
 B/c used to pumping while pt flat
 Pt gets lightheaded & BP drops
 Pt lacks endurance
 Be careful what have pt do if have been on BR for awhile
• Blood clots
 DVT
 Blood pools & forms clots
 Don't put anything right under knees b/c can contribute to clot formation
 Lower extremeties mostly
 Pt becomes achy
 Don't massage legs b/c if is blood clot, it can loosen
 Can put lotion on them
 No crossing legs in bed
• Causes clots
 Blood clot suspected
 Put on BR immediately & report it to doctor
 Virchow’s triad
 Impaired venous return
• Lying in bed
• Not moving legs
 Hypercoagulability
• Blood clots easier when thick
• Decreased hydration
• Allowed to pool & then components settl
• Provide adequate fluids
• May put pt on anti-coagulants
 Injury to vessel walls
• Surg to legs
• Crossing legs
• Hitting legs
• Heart becomes deconditioned
 Can only meet basal metabolic needs
 Can use activity intolerance
 All activity will put strain on heart
 Leads to increased angina
 Heart meets need of pt lying still
 Leads to activity intolerance
• Ambulate pt
 Most pt’s on BR do not drink enough
 Could lead to blood clots
 PE
• Clot dislodges
 Could happen immediately
• Goes to lungs
 Pt turn dark color from nipple up
• Cuts off circulation
• Most often fatal
• S/S
 Sudden onset of chest pain
 Cyanosis
 Respiratory distress
 Dyspnea
 Tachypnea
 Shock
 Extreme restlessness
 Anxiety
• Interventions
 Support c oxygen
 Put head of bed in semi-fowlers
 Use anti-coagulants until clot dissolves
 TED hose
 Knee or thigh high
 Have pressure gradient built in them
 Helps c venous return
 Helps c clot prevention
 Has to be measured for pt
 Ease on inside out
 Make sure not twisted
 Have pt lay c leg elevated to drain
 Pt complains of pain in lower legs when walking
 Immediately put pt back in bed
 Tell pt not to move
 Should be taken off at least q8hr
 Should leave TEDs off about 20 minutes
 TEDs put on right can help
 TEDs not put on right can cut off circulation
 Aids c circulation
 Has hole to see toes & nails
 Once pt discharged see what dr wants to do c hose
 Usually discontinue use
 SCD, PlexiPulse, or Impulse Boots
 Pulse blood up leg
 They can work on either legs or feet
 Metabolic/nutrition system
• Decreased basal metabolic rate (BMR)
 Only functions c minimum amounts of energy body needs to stay still
 Gastric motility & secretions decrease
 Constipation
 Anorexia
 Causes imbalance in protein
 Protein synthesis (anabolism)
 Protein breakdown (catabolism)
 Negative nitrogen balance b/c of muscle breakdown
 Seen c increased urine urea nitrogen test
 Excess protein excreted in urine
 Pt will heal slower
 Ca++/bone loss
 Ca++ extracted from bones faster than brought in
 Need weight bearing on bones
• Don't have weight bearing on BR
• When absence of weight bearing & stress there is loss of Ca++
 Urinary system
• Affects kidneys & bladder b/c of gravity
• Don't completely empty bladder
 Causes
 Pooling of urine
 Urinary stagnation
 Decreased muscle tone of bladder
 Kidney stones
 Chance increases on 2nd-3rd day of not completely emptying bladder
 Renal calculi
• Infection from stasis or catheter
 UTI
• Incontinence
 Loss of muscle tone
 Urine escapes
 Causes dribbling
 Then urine lost
 Happens b/c pts have trouble urinating on bed pan
• Urinary retention
 Urine stay in bladder
• Catheters
 Adhere to strict sterile technique when emptying or replacing bag
 Tubing should be at level of bed to provide an easy flow pattern
 Careful not to pull on tubing b/c it can hurt pt
 Tape to leg
 Don't hold bag above level of bladder
 Tearing of lining of bladder R/T distention
• Urinary reflux
 Urine can back up into kidneys from distention
 Can cause nephritis & kidney failure
 Can end up c sepsis
 Turning or moving pt
 Kink tube & put rubber band
 Prevent backflowing
 Body sterile
 Once urine leave body is not sterile any more
 Do not want it to backflow
 Keep bag below bladder at all times
 GI system
• Note bowel habits on I&O sheet
• Constipation
 Decreased gastric secretions
 Decreased motility
 Decreased muscle strength
 All lead to constipation
 Frequent problem c immobile pts
 Commonly have dehydration
 Stool is harder & firmer
• Use of bedpans
 Embarrassing
 Difficult to use
 Commonly use Valsalva maneuver
 24 hrs s bowel movement
 Start Tx
• Anorexia
 Lack or loss of appetite
• Bowel impaction
 Integumentary system
• Increases vulnerability
 Thin skin
 Lack of nutrition
 Especially c OA & malnourished
• Skin breakdown
 Atrophy of skin from decreased nutrition R/T anorexia
• Decreased healing
• Mechanical effects of lying in bed
 Friction
 Shearing
 Pressure
• Do complete skin assessment
• Anytime see reddened area
 Report it
 Keep pt off of it
• Don't massage areas of breakdown
• Turn pt q2h or more
 Doesn't always get done
 Musculokeletal system
• Decreased strength & movement
 20% of strength lost after one week of BR
 Decreased endurance contributes to activity intolerance
 R/T BR deconditioning
• Atrophy
 Loss in muscle mass
• Muscle dysfunction will cause joint dysfunction
• Ankylosis
 Joint is fixated or frozen
• Contractures
 Limbs pull towards stronger of muscles
 Fetal position
• Osteoporosis
 Loss of Ca++ in bones which causes to be brittle & easily broken
• Disuse osteoporosis
 Demineralization of bones
 Happens on 2nd-3rd day on BR
• Chart on p. 1126
 Psychosocial effects
• Depression
• Behavioral changes
• Altered sleep-wake cycle
 Difficulty sleeping b/c not doing anything
 Not tired
• Decreased coping abilities
• Increased isolation
• Sensory deprivation
 Not lot of stimulation
 Talk to them
 Do some things to help distract them
 Developmental effects
• Decreased progression through developmental tasks
• Increased dependence o Interventions
 Repositioning
• Q2hr at least
• Tailor to pt
• Maintain alignment
• Protect pressure points
• Teach pt to shift positions
• Keep bones & joint moving
 Leg exercises
• Q1-2 hr
• Relax & contract muscle
• Move feet back & forth
• Move knees up & down
• Teach or assist pt
• Will help prevent DVT
 Weight bearing activities
• Stand pt if possible
• Sit up & put feet on floor
• Early ambulation
• MD has to order when pt can get up from BR
• Have beds that can move around & rotate pt
 ADLs & IADLs
• Encourage pt to do self care
• Fosters independence
• Increases self-esteem
 ROM exercises
• At least TID
• Do as much as possible when c pt
 TED hose
 Deep breathing & coughing (DB&C)
• Learned about c oxygenation
 Breathing exercises
 Discourage Valsalva maneuver
• Causes an increased venous pressure
 Discourage leg crossing
 Encourage fluids & nutrition
• Bring things pt likes to eat & drink o Nursing Dx
 Pt activity intolerance
• Has to do c endurance
• Care plan has to have activity levels
• R/T Oxygen supply/demand
 Don't use c Fatigue
 Can be R/T pain
 Fatigue
• When pt rests & doesn't feel better
 Chemotherapy pts
 End Stage Renal Disease pts
• Don't use c Activity Intolerance
• Not being able to perform activities
• Can tell if is fatigue if pt can take nap & feel rested or better
 That pt just tired not fatigued
 Impaired Physical Mobility
• Broken leg
• Broken R arm c R handed pt
 Disuse Syndrome
• Totally immobile
 Pt in coma or paralyzed
 No R/T
 Look in Carpentio
 See if there is list of HR Dx that encompass this
 If pt develops one of these HR Dx as problem
 Add as additional Dx in addition to disuse syndrome
 If pt will not ever be able to move again
 Do not put pt will increase mobility
 Focus will be to prevent constipation
 Prevent disease or problems
 Self-care Deficit
• Specify
 Bathing/hygiene
 Grooming/dressing
 Feeding
 Toileting
 Instrumental
• Use only if they have 1 or 2 of these
• Must be reasonable
 Self-care Deficit Syndrome
• Use if pt has all 5
 Constipation
• HR or actual
 Perceived constipation
 Diarrhea
 Impaired Urinary Elimination
• Retention
• Functional incontinence
 Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine
• Reflex incontinence
 Involuntary loss of urine at somewhat predictable intervals when specific bladder volume is reached
• Stress incontinence
 Sudden leakage of urine occurring c activities that increase abdominal pressure
• Total incontinence
 Continuous & unpredictable passage of urine
• Urge incontinence
 Involuntary passage of urine occurring soon after strong sense of urgency to void
 Hospitals won’t be paid for the following conditions if occurs in hospital
• Hospital-acquired injuries
 Including fractures, dislocations, & burns
• Mediastinitis after CABG
• UTIs from improper use of catheters
• Pressure ulcers
• Vascular catheter-associated infections
 Never paid for following events:
• Objects left in the body during surgery
• Air embolisms
• Blood incompatibility