• Patient name
• date/time of prescription
• medication name
• amount, time and frequency of dose
  
• route of administration
• signature of prescibing provider

• right patient
• right drug
• right dose
  
• right route
• right time
• right documentation
  
  • check dose 3X before giving
  • never give med you didnt prepare

Controlled substance

(I)

Controlled substance

(II)

Controlled substances

(III)

Controlled substances

(IV)

Controlled substances

(V)

• Kept in secure locked area
• Ordered by a licensed prescriber
  
• choose size closest to dose being ordered
• counted every shift by 2 nurses

• reflects the patient care delievered
• communication between health care professionals
• legal record care was provided
• demonstrates compliance with professional standards, rules regulations
  
• justify financial reimbursement

Factual: objective data as much as possible

Accurate: specific and concise

complete:clear picture of event

current: chart soon after event

Organized: note should read with an organized flow to it

• Legibility
• standardized quality of forms
• merges flowsheets/decrease repeat charting
• easy to find information
• tracks changese to the record and who is making them

• Computer crashes
• learning a new system
• confidentiality

Giving medication through tube

NG/NGT

• Check the tape is at level of nares
• it must have been comfirmed by x-ray
• first- flush 30 ml of water through tube
• 2nd- give med
• 3rd- flush with 30 ml of water

Automated Medication Dispensing System

(AMDS)

control the dispensing of all medications, including narcotics.

This system causes the drawer containing medicaiton to open, records it, and charges it to the client.

• easiest and most desirable way to administer meds
• importnat precaution to take when administering these meds is to protect clients from aspiration.

Meterd-dose inhalers

(MDI)

• deliever a measure dose of medication with each push of a canister
• they are either squeeze and breathe and requires the client to apply approximately 5 to 10 pounds of pressure to the top of the canister

Needle sizes

1.  do not contaminate one medication with another
2. ensure the final dose is accurate
3. maintain aseptic technique

• placing meds into the losse connective tissue under the dermis
• absorption is somewhat slower
• sites are: outer posterior aspect of the upper arm, abdomen,anterior asepect of the thighs.
• pitch area of injection
• can go in at a 45 or 90 degree angle
  

Low-molecular weight heparin

(LMWH)

• when injecting use the right or left side of the abdomen
• pinch the injection site
• in a prefilled syringe with the attached needle, do not expel the air bubbles in the syringe.

• faster med absorption
• can cause more infections
• longer and heavier-gauge needle
• has to be 90 degree angle
• sites- vntrogluteal muscle, vastus lateralis, deltoid, dorsogluteal.

used to minimize local skin irritation by sealing the medicaiton in muscle tissue.

pulling on overlying skin during IM injection moves tissue to prevent later tracking

• skin testing
• potent so injected to the dermis
• absorbed slowly
• inner forarm and upper back
• 15 degree angle