Thursday, March 17, 2011

The Six Rights of Medication Administration

You thought there were only 5 Rights of Medication Administration, didn't you? Well, one of the important rights gets commonly left out of the mix. Medication administration is probably one of the scariest things to learn as a new nurse and it is also probably one of the most dangerous. We always need to remain alert and cognizant when we are preparing medications. You can reduce your risk for medication errors by preparing medications for only one patient at a time and by always following the 6 Rights of Medication Administration.

Let's take a look at all of the rights.

Right Patient - Make sure you are preparing medications for only one patient at a time. This helps to reduce errors and confusion. Label any drugs that you have to prepare in the med room. No meds should go into a patient's room without a label. Check each medication against the patient's arm band, don't just check the first one you give. This helps to reduce errors from accidentally having a medication for another patient in the room with you. If you check each medication against the patient's ID then you are not only checking the patient's ID but you are also checking to be sure each medication that you have in the room is prescribed for that patient.

Right Drug - Always be sure to check the label of your drug for the correct patient name and the correct drug name. Take extra care with drugs that look alike/sound alike such as Xanex and Zantac. Think about your patient and if the medication you are giving makes sense for the patients diagnoses. Ensure that you are getting another RN to sign off on any high alert medications. Each hospital should have a policy around what constitutes a high alert medication. The Institute for Healthcare Improvement has a web page dedicated to high-alert medications.

Right Dose - Ensure that the dose you are giving is the dose that has been ordered. If your drugs come ready to give from the pharmacy, the pharmacist will check this and then the RN is the double check. Don't not check dosages because you think the pharmacy has already done this. Errors can occur at any step during the process but YOU are the last line between a medication and a patient so it is imperative that you go through the 6 Rights. Check your dose against what is ordered on the Medication Administration Record and be sure that the dose is within the limits for the patient's weight. Also, if your drugs do come up ready to give from pharmacy, ensure that the dose ordered is actually what is in the syringe. If the label reads that 20 mg should be 0.5ml, be sure that 0.5ml is actually what is in the syringe and not just that it says 0.5ml on the label.

Right Time - Be sure you are giving a dose at the right time. Check your MAR for the times that the drug has been ordered and check to be sure you are the correct interval away from the last dose. For instance, if you have a medication ordered q12 hours and dose you are giving is at 0800, be sure that the last dose was given at 2000 the previous night and that it wasn't given late (say 0100) for some reason. Be sure that medications ordered q8 hours are actually timed for q8 hours.

Right Route - Always be sure that you are giving a drug via the route that is ordered. Be careful with drugs that can be given via multiple routes and check to see that you have the right medication for the right route. In other words, if you are giving Zantac IV, be sure you don't have an oral formulation for that drug. The drug label should specify the route and many hospitals use different types of syringes for oral and IV medications as a safety precaution. Never give a drug via another route other than what is ordered unless you check with the provider or the pharmacy.

Right Documentation - This is the 6th Right that is commonly left out! After you give a medication, you need to be sure to properly document it's administration. If you don't, you run the risk of you or someone else causing a medication error because they didn't know that the drug had been given (or you didn't remember that you gave the drug!). This can happen more easily than you think when you are caring for multiple patients to be sure to take the time after your medication administration to properly document what you have given. Always document your drugs given AFTER they have been given and not before. Any number of things can happen when you go in a room to give medications that might prevent you from giving the med. If your patient is on strict I&Os, be sure to record the volume of any meds that were given as well. Remember that the MAR is a very important communication tool between nurses and other health care team members. Have some sort of system on your nursing "brain" that tells you when you have given and documented a medication. For instance, on my own nursing brain, I put circles around and highlight all of my medication time. Once I have given the medication, I put one line through the time. Then, once I have documented the medication, I put another line through it making an X. That way, I can easily look at my nursing sheet and see what I need to give and what I need to document.

Here is a link to the Institute for Healthcare Improvement's medication safety guides.

Slow down when you are giving medications and take the time to go through all of these rights every time. No amount of needing to "hurry up" is worth causing a medication error for a patient.

On another note - most hospitals have a system for reporting and tracking any kind of error or near miss. Anytime you have a medication error or almost have a medication error, be sure to document it through this system and NOT in the patient's chart. Systems keep track of errors and near misses so that they can make system safety adjustments to try and prevent future errors. In order to do this, they must have current data. If you do have an actual medication error, contact the provider and your manager right away. You will probably also need to contact your hospital's Risk Department to ensure that you are following up with the patient and with documentation according to hospital policy.

Wednesday, March 16, 2011

Nursing Assessment


Here is an example of a good, thorough nursing assessment for a patient in the hospital for short gut
syndrome.

General Assessment: C.H is a 10-month-old African American male currently admitted for short gut syndrome, not tolerating feeds and weight loss. Patient appeared awake and alert but fussy and irritable,with minimal signs of distress, due to morning episode of emesis. Pt. is small for age.

Vitals:  P: 1 (FLACC scale); HR: 121 ; RR: 44; T: 36.5 C; BP: 103/59 MAP:71; Wt. 5.2kg

Review of Systems:

Integumentary: color appropriate for race, warm to touch, dry and smooth, turgor good, no lesions. No clubbing, nail beds pink, temperature even bilaterally in extremities. Patient has PICC line in his right AC. Patient has continuous TPN infusing through PICC line at 14ml/hr and lipids infusing at 1.5ml/hr. Both cycle for 24 hours. No redness or infiltration of line noted, flushes well. PICC line labeled with necessary dressing date change. Dressing on PICC line is CDI. HEENT: normocephalic & symmetric head, no tenderness or lesions. PERRL but lacks accommodation. Corneal light reflex symmetric bilaterally. Unable to track objects or sound with eyes. No obvious hearing impairment or visible discharge from ears. Nose symmetric, nares patent, no discharge. Respiratory: Breath sounds clear in all fields bilaterally, no adventitious sounds. No increased WOB, chest expansion symmetric, slight retractions present during morning episode of emesis. No evidence of aspiration post-emesis. Cardiovascular: Regular rate & rhythm, S1/S2 present and not diminished or accentuated, no murmurs noted, no S3/S4. Pulses 2+ and equal bilaterally in all extremities. CRT < 2 seconds all extremities. Apical pulse present 5th ics at left midclavicular line. No heaves.  GI/GU: abdomen round, soft and slightly distended, hyperactive bowel sounds present all 4 quadrants, no vascular sounds noted. Scars present across entire front of abdomen due to several abdominal surgeries related to the short gut.  Scars are well healed and well approximated. Patient has accessed G-tube in LUQ with enfacare 20 Kcal infusing at 42ml/hr x 20 hours/day. Dressing intact, no redness or drainage around site.  2 episodes of emesis prior to 10AM this shift. Emesis episodes were approximately 30ml of undigested formula. Pt. has good urine output evidenced by several wet diapers this shift. Last BM 0930 was loose, light brown stool. Musculoskeletal System: Full ROM in all extremities, no joint swelling or deformities.  Poor muscle tone noted, weak grasp. Lack of head control in the same plane as body when supported in sitting position. Pt. not able to sit up unassisted.  Neurological: Awake and conscious. Smiles appropriately in response to staff attention.  Lacks rooting and Landau reflex. Weak palmar grasp present bilaterally.
Developmental: Patient has not met appropriate developmental milestones AEB lack of several key milestones for age. Pt. unable sit up or pull himself up to a standing position. Patient has not shown any signs of crawling or rolling over. Patient not able to transfer object from between hands or grasp using fingers and opposing thumb. Pt. has limited amounts of babbling and no words were formed. No use of hand gestures, such as waving “bye.” Pt. not consistent with eye contact and does not turn head towards sound though he does respond to noises. Pt. receiving PT and OT several times a week and is improving his muscle tone and working on tasks such as head control.  

Tuesday, March 15, 2011

Assessments

One of the major things we learn to do in nursing school is how to write a good assessment, right? This can be a daunting task. One of the best ways to learn to do assessments is to pick a routine that works for you and stick to it. However, when you are dealing with pediatric patients, you have to be a little bit flexible with your order! This is why I teach my students to really think about your patient, think about what is going on with them and make sure you check the most important things first. For instance, if you have a patient with asthma exacerbation, you would want to be sure and do your respiratory assessment first or at a time when the child is calm (like when sleeping for instance). When dealing with pediatric patients, you never know how far you will be able to get into your assessment before there is a melt down and then you can't hear anything. So, think about the most important things to assess on your patient so you can be sure to get those done.

Also, it's perfectly fine to do a lot of your assessment with the caregiver holding the child. If this helps the patient be more calm and feel more secure, then try to do what you can with them in the caregiver's lap. You can't do this for all parts of the assessment or all procedures, but try to work this into your assessment when appropriate. If your patient starts crying in the bed, try giving them to the caregiver to see if that will help you get a little further along.

Don't forget that everything around the patient is a part of your assessment as well! You should always be checking lines, IVs, machine settings and the patient's environment with every assessment. This is especially true with pediatric patients. Be sure that no one has left caps or other small items in the bed that might pose a choking hazard for a small child. Don't forget bed and crib rails too! A safety assessment should be a part of what you do every time you walk into the room. Keep in mind that you may have patients that are developmentally delayed so even if you have a child that really should be past the point of putting everything in their mouth, they may have a developmental delay that causes them to have behaviors common to earlier stages of development.

So, how do you write up your assessment? Try to do your write-up in the same order every time so that you don't miss anything. Be sure to include anything that is unique to the child. Don't just write a "normal" assessment. Document lines, G-tubes, scars, abnormals, etc. that are unique for the patient.

Start EVERY assessment with a brief description of who your patient is. It is difficult to put the information in your assessment into context if you don't tell me a little about the patient on the front end. Don't forget to include your vital signs (including pain [don't forget to list the pain scale!] and weight). For pediatric patients, I always require my students to add a statement about development as well. Just add a blurb at the end about whether or not the patient has met their developmental milestones on time and if so, how that is evidenced. Also, DO NOT write "normal" or "within normal limits" for any of the systems. As an instructor, I need to know that you know what normal is! So, don't write: CV: WNL. You need to write something like: CV - Regular heart rate and rhythm, no murmurs noted, s1/s2 present, no s3/s4 noted. PMI is palpable at 5th ics. No heaves. - or something to that effect. Now I know that you know what you are looking for when assessing the CV system.

Watch for tomorrow's post where I will post an example of a good, complete pediatric assessment.

Monday, March 14, 2011

SBAR

What is SBAR? SBAR is a form of reporting that is used to increase the continuity of care and patient safety. SBAR is a technique used for health care providers to talk about a patient's condition. SBAR is not a repeating of a full patient assessment. SBAR requires you to pull out only the most pertinent information related to a patient's condition to pass onto a provider, another nurse or another member of the patient's health care team. Let's look at what SBAR stands for and what information you would put in it.

SBAR stands for Situation, Background, Assessment and Recommendations. My clinical students turn in journal entries. Each journal must contain a full head-to-toe assessment on their patient and an SBAR report. This is required so that students will learn what information from a patient assessment is important to pull out for the SBAR. SBAR is NOT a repeat of everything in a patient assessment! That would take too long and is not necessary every time we communicate about a patient's condition. I want my students to practice pulling out relevant information for an SBAR report. Efficient communication is an important skill for nurses to learn.

Situation - This is a brief summary of the patient's condition. Anything related to the patient's current condition is related here. ALWAYS start this section with a brief description of the patient (name, age, sex, diagnosis, etc.). If you don't, the rest of your SBAR is not going to make sense. The person you are speaking with must have this pertinent information in order to put the rest of your conversation in context.

Background - This is a brief summary of the patient's past medical history. Anything that is related to the patient before this current admission goes here.

Assessment - This is your assessment of what is currently going on with the patient. If you are required to use nursing diagnoses, these go here.

Recommendations - This is a section for what you think needs to be done in order to address the patient's situation. If you have listed any nursing diagnoses in the "A" section, the "R" section is where you will list the tasks you will do in order to address those nursing diagnoses.

SBAR will look a little different depending on who you are giving report to and how detailed that report needs to be. For instance, if  you are calling a provider about your patient spiking a fever, you would probably give a very brief SBAR report unless you are calling a provider that is not familiar with your patient's case. If you are giving report to another nurse for shift change, your report will probably be a bit more detailed.

Let's look at an example. Let's say you are giving RN to RN shift report on a 14 year old patient admitted for asthma.

S - This is Jane Doe, 6 year old patient of Dr. Jones admitted on March 13th for an asthma exacerbation. Mom reports that Jane began having cold symptoms 4 days ago. Jane has NKA. Last VS - HR-109, RR-32, BP-112/72, T-38.2, P-0 (FACES scale), weight-42 kg. Currently, she is on room air and her sats have been between 96 and 98%. She has not required any oxygen for me on this shift but has remained slightly tachypnic during the day. She still has some expiratory wheezes. Her breath sounds are clear but diminished in the LLL. She has a BVM at the bedside. She still has not been eating or drinking well so I have kept her D51/2 NS with 20 of K running at 45ml/hr. She has a PIV to her left forearm that is infusing well. The site is non-edematous and non-painful and the dressing is clean, dry and intact. She has good urine output and has voided 4 times on my shift with the smallest measured amount at 150ml. Her last BM was yesterday afternoon. Bowel sounds are present in all four quadrants and her abdomen is non-tender and non-distended. She has been receiving albuterol treatments q 4 hours, 20mg of prednisone q 6 hours, 500mg of Amoxicillin BID and has not required any PRN medications for pain or nausea on my shift.  She did have 650mg of tylenol on the previous shift at 2200 for a headache and this seems to have resolved.

B - Jane has no significant PMH other than a diagnosis of asthma made 2 years ago. She has never been hospitalized for her asthma before. Mom reports that she ran out of Jane's ashtma medication prior to her current admission. Jane is developmentally appropriate and mom reports she has met all developmental milestones on time. Jane was a single, normal, vaginal delivery with no complications. She is UTD on her vaccinations.

A - 1) Risk for airway compromise r/t diagnosis of asthma  2) Risk for nutritional deficits r/t decreased appetite

R - 1) Keep Jane on an oxygen saturation monitor in order to monitor sats, perform frequent respiratory assessments in order to identify increasing airway compromise in a timely manner, monitor VS for tacycardia, tacypnea and fever. Encourage IS use q 2 hours WA as ordered. Look for early signs of increased WOB and educate family about S&S to watch for in order to promote early intervention. Intervene immediately for any late signs of respiratory compromise such as retractions, nasal flaring or decreased oxygen saturation. Ensure emergency equipment, BVM and code sheet are present at the bedside. 2) Encourage patient to eat and encourage mom to order patient's favorite foods from cafeteria. Encourage fluids, jello and popscicles. Keep patient on IVF until PO intake increases and monitor UOP, skin turgor and LOC for any S&S of dehydration.

Now, let's say you needed to call a provider to let her know that your patient, Jane Doe, has spiked a fever. Dr. Jones is familiar with your patient and saw her this morning on rounds. Your SBAR would look a little different.

S - Hi Dr. Jones, this is Brittany on 4E calling you about Jane Doe, 6 year old patient here for asthma exacerbation in room 4228. She is having some increased wheezing from this morning and she now has a fever of 39. She still has low PO intake but her fluids are still infusing without incident at 45ml/hr.

B - Jane has no significant PMH other than her asthma diagnosed 2 years ago.

A - It looks like Jane is starting to spike fevers again despite her current antibiotics. Also, her wheezing is increasing.

R - Jane is getting her antibiotics as scheduled but I am concerned that they aren't covering her based on her continued fevers. Would you like to change or add any antibiotics at this time? In addition, I would like for respiratory to come see her again and evaluate her for a treatment. Also, her last chest film was 1 week ago. Would you like a repeat film?

See how those two SBAR reports look a little different for the same patient depending on who you are giving the report to and the reason for the report?

Here are some additional resources on SBAR.

This site has information about SBAR and a link to some SBAR worksheets that may help you in writing out your SBAR report - http://www.saferhealthcare.com/sbarsamples.pdf

You can also look at the Institute for Health care Improvement website and type SBAR into the search feature for more good information - http://www.ihi.org/ihi

Sunday, March 13, 2011

Welcome to the Nurse Ed blog!

Welcome! This blog is dedicated to all different types of nursing education. I would like to use this forum to talk about current trends in nursing and talk about things in clinical practice that may be useful for nursing students. Feel free to leave comments or send me an email at brittanymnewberry@gmail.com about topics you would like to see covered. Before we get started, let me introduce myself a bit.

My name is Brittany Newberry and I am a graduate of Emory University in Atlanta. I completed my BSN in 2001 and my MSN/MPH degree in 2003. My MSN is a Family Nurse Practitioner degree and my MPH degree is in Environmental and Occupational Health. Currently I am working on my PhD in Educational Technology at Northcentral University.

Currently, I teach a pediatric clinical rotation at Children's Healthcare of Atlanta for both Junior and Senior nursing students. Before coming to Emory, I worked at Children's Healthcare of Atlanta as a staff nurse in neurology/neurosurgery and then as a nurse educator for that same floor. I then went on to work as the nurse educator for the outpatient immediate care, primary care and specialty care clinics associated with Children's Healthcare of Atlanta.

I am originally from Atlanta. My husband and I currently live in Blue Ridge, GA so I commute to Atlanta once a week. We recently got an apartment near the Emory campus so we load up our dog and one of our cats for the journey each week! The other 2 cats and the 10 chickens stay in Blue Ridge. In my spare time, I love to do outdoor activities like hiking, walking, canoeing, camping and kayaking. I am also an avid reader and knitter. My husband and I run a small knitting company where we sell hand-dyed yarn, knitting pottery (my husband is the potter!) and we have lots of educational videos about knitting and crochet on YouTube. If you want to learn to knit in your spare time to relieve some nursing school stress, you can go to www.knitwitch.com!