SUR

HAN GICAL
DWA
S HI
NG
 GENERAL OBJECTIVE
 After the discussion and
demonstration, the BSN 2
students will able to
develop positive attitude,
acquire basic knowledge
and skills on surgical hand
washing.
 SPECIFIC OBJECTIVES
 The BSN 2 students will be able to:
 1. Recognize the importance of
Surgical Handwashing in preventing
the spread of infection during a
procedure.
 2. Follow the principles of sterile
technique at all times during a
procedure.
 3. Define related terms correctly.
 SPECIFIC OBJECTIVES
 4. Practice the procedure at home
following the steps written in RLE
Manual.
 5. Prepare the materials needed in
Surgical Handwashing before a
procedure.
 6. Return Demonstrate Surgical
Handwashing utilizing the correct
steps written in RLE Manual.
PRINCIPLES OF
STERILE TECHNIQUE
 All objects used in a sterile field must
be sterile.
 A sterile object becomes non-sterile
when touched by a non-sterile object.
  Sterile items that are below the
waist level, or items held below waist
level, are considered to be non-
sterile.
 Sterile fields must always be kept in
sight to be considered sterile.
 When opening sterile
equipment and adding supplies
to a sterile field, take care to
avoid contamination.
 Any puncture, moisture, or tear
that passes through a sterile
barrier must be considered
contaminated.
 Once a sterile field is set up,
the border of one inch at the
edge of the sterile drape is
considered non-sterile.
 If there is any doubt about the
sterility of an object, it is considered
non-sterile.
  Sterile persons or sterile objects may
only contact sterile areas; non-sterile
persons or items contact only non-
sterile areas.
 Movement around and in the sterile
field must not compromise or
contaminate the sterile field.
Data source: Kennedy, 2013; Infection
Control Today, 2000; ORNAC, 2011;
Perry et al., 2014; Rothrock,
2014Critical Thinking Exercises.
 Sterile technique is most commonly
practised in operating rooms, labour
and delivery rooms, and special
procedures or diagnostic areas.
 It is also used when performing a
sterile procedure at the bedside,
such as inserting devices into sterile
areas of the body or cavities (e.g.,
insertion of chest tube, central
venous line, or indwelling urinary
catheter).
 In health care, sterile technique is
always used when the integrity of
the skin is accessed, impaired, or
broken (e.g., burns or surgical
incisions). Sterile technique may
Surgical Handwashing
is the removal of as many
microorganism as possible from
the hands and arms by
mechanical washing and chemical
disinfection before taking part in a
surgical procedure.
Antimicrobial agent – used for
cleaning the skin of patients and
caregivers that has a fast-acting
broad-spectrum action to reduce
the count of microorganism before
a surgical procedure, capable of
destroying or preventing the
growth of microorganism.
 Surgical scrub – is the
removal of as many bacteria
as possible by means of
mechanical washing and
chemical disinfection before
taking part in a surgical
procedure
 Complete scrub –
scrubbing usually takes in
about 10-15 minutes
 Short scrub – scrubbing
that usually takes in 3-5
minutes
 Contamination – introduction
of pathogens into a normally
sterile field
 Friction – the rubbing of one
body against another; often a
strong circular manipulation
 Subungual – under the
fingernails
 Sterile
– without
micoorganism
 Sterilization-the process of
removing all microorganisms
including the bacterial spores
 PURPOSE
 Help prevent the possibility of
contamination or the operative
wound by microorganism on hands
and on the arms
 Todecrease the number of resident
microorganism on skin to irreducible
minimum.
 Tokeep population of microorganism
minimal during the surgical
procedure by suppression of growth
 Points to
Remember:
 Rinse as often as possible using one
direction only. Start from the hand
going to the arm taking care not to
touch the faucet and the sink.
 A person with cuts or burns should
not scrub because of high bacteria
count
 The hands and arms can never be
rendered sterile no matter how long
the scrubbing is nor how strong the
antiseptic.
 Surgical scrubbing is most
effective when firm motion is
applied.
 Use an ample amount of
antiseptic in scrubbing
 Hands should be kept higher
than the elbows after a scrub
to prevent running of water
back to the scrubbed hands
 STEPS
 PREPARATION:
 1. Deep sink with foot or knee controls for
dispendsing water and soap (faucets
should be high enough for hands and
forearms to fit comfortably
 Antiseptic detergent/soap
 Surgical scrub brush with plastic nail and
pick
 Mask, cap or hood
 Sterile towel
 Scrub suit attire
 Protective eyewear (glasses or googles)
 Procedure:
 1. Apply surgical attire: shoe covers, cap or
hood, face mask and protective yowler.
 2. Turn on water knee or foot controls and
adjust to comfortable temperature.
 3. Wet hands and arms under running
lukewarm water and lather with
detergent/soap up to 2 inches above the
elbows ( Hands need to be held above
elbows at all times.)
 4. Rinse hand and arms thoroughly under
running water. Remember to keep hands
above elbows.
 5. Under running water, clean under nails
both handles with file. Discard after use.
 6. Wet brush and apply antimicrobial
detergent/soap.
 7. Scrub the nails of one hand with 15
strokes.
 8. Holding brush perpendicular, scrub
the palm, each side of the thumb and
fingers and the posterior side of the
hand with 10 strokes each.
 9. The arm is mentally divided into
thirds and each is scrubbed 10times.
 10. Entire scrub should last at least 2-
3 minutes.
 11. Rinse brush and repeat the
sequence for the other arm.
 12. Discard brush and rinse hands and
arms thoroughly. Turn off water with
foot or knee control and back into
room entrance with hands elevated in
front of and away from the body.
 13. Bending slightly forward at the
waist, use a sterile towel to dry one
hand thoroughly moving from fingers
to elbow. Dry in a rotating motion. Dry
from cleanest to the least clean area.
 14. Repeat drying method for the
other hand, using a different area of
the towel or a new sterile towel.
 Kennedy, 2013; Infection Control Today, 2000; ORNAC, 2011; Perry
et al., 2014; Rothrock, 2014
 Link: https://opentextbc.ca/clinicalskills/chapter/surgical-asepsis/
 Link:
https://www.albertahealthservices.ca/assets/wf/eph/wf-eh-surgical-
aseptic-technique-sterile-field.pdf
 Pictures taken from:
 Business law donut
 Dreamstime.com
 Johns Hopkins Medicine youtube account
 Shutterstock.com
 Depositphotos
 Favpng.com
 systemicleadershipinstitute.org
 Gowning
and Gloving
Technique
 General Objectives:

 After the discussion and demonstration, the

BSN 2 students will able to develop positive
attitude, acquire basic knowledge and skills
in Gowning and Gloving Technique
 The BSN 2 students will be able to:
 1. Recognize the importance of Gowning and
Gloving Technique in preventing the spread of
microorganism during surgical procedure.
 2. Follow principles in maintaining sterile field
during gowning and gloving technique strictly.
 3. Define related terms correctly.
 4. Practice the procedure at home following
the steps written in RLE Manual.
 5. Prepare the materials needed in Gowning
and Gloving Technique before a procedure.
 6. Return Demonstrate Gowning and
Gloving technique utilizing the steps written
in RLE Manual.
 Maintaining a Sterile Field
 The surgical team should take precautions to avoid contamination and
maintain the sterile field.
 The hands should be kept above the waist and insight at all times.
 The sterile areas are:
1. The front of the gown from the table level or sterile field to two inches
below the neck
2. The sleeves from two inches above the elbow to the cuff
3. The surgical gloves, the underarms are considered nonsterile.
The back of the gown is not considered sterile even if it is the
wraparound style.
If any part of the sterile attire becomes contaminated,
immediate corrective steps must be taken (e.g. if a glove
becomes contaminated, it must be changed immediately
(Association of Operating Room Nurses (AORN) Standards of Care, 02/07).
 GOWNING
 A procedure that is practiced after a
surgical scrub
 Is done after a personnel has scrubbed
 A sterile gown must be worn in order to
permit the one who wears it to go near
and touch sterile items within the sterile
field
 Can be done unassisted or assisted.
Unassisted gowning is done by the
person who will wear the gown, while
assisted gowning is done by a
gowned personnel serving the person
who will wear the gown
 Surgical gown – a garment used
in surgery
Parts:
a. Right side
b. Wrong side
c. Body
d. Sleeves
e. Cuffs
f. Neckband/neckline
g. Belt
h. Hemline
i. Back
GOWNING
TECHNIQUE
 PROCEDURE:
1. Reach down top the sterile table and grasp
the whole gown directly upward.
2. Step far enough away from non-sterile area
or objects.
3. Hold the area of the gown near the
neckband with both hands and gently
unfold the gown locating the armhole. The
gown must be facing on the wrong side
part. Touching only the wrong side out.
4. Slip the hands into the armholes, placing
hands upward in the level with the shoulder.
 PROCEDURE:

5. Bend slightly forward, swing the belt to be

tied at the back by the circulating nurse.
6. The Rest of the back ties will be tied by the
circulating nurse.
7. Position hands in upward position, hands
should not be placed below the waistline.
Bare hands must not slip out from the
surgical gown to maintain sterility.
 T O
 This is done after a surgical scrub
T S
O IN B E R
 Use an oscillating motion to dry the P E M
hands and arms. Start from the
RE M
hands going to the arms. Use the
hemline of the gown in drying
 In putting on and serving a gown, do
not turn your back from the sterile
team field to avoid contamination
 In picking up a gown from the pack,
be careful not to touch other sterile
items with your bare hands other
than the gown you will use
 The surgical team should take precautions to
avoid contamination and maintain the sterile
T O
field. T S
O IN B E R
 The hands should be kept above the waist P E M
and insight at all times.
RE M
 The sterile areas are:
1. The front of the gown from the table level
or sterile field to two inches below the neck
2. The sleeves from two inches above the
elbow to the cuff.
3. The surgical gloves The underarms are
considered nonsterile. The back of the
gown is not considered sterile even if it is
the wraparound sfyle. If any part of the
sterile attire becomes contaminated,
immediate corrective steps must be taken
(e.g. if a glove becomes contaminated, it
must be changed immediately).
 Gloving
Technique
 Gloves are packaged so that
the scrub may don his gloves
without contaminating the
glove’s outer surfaces. A pair
of gloves is packaged in an
individual sterile wrapper.
 Gloving is done after the
personnel has donned a gown.
This is also the last phase to
complete the sterile attire
in order for the personnel to
handle sterile equipment.
 Open gloving – method of
putting on a glove without a
surgical gown
 Closed gloving - a
procedure of putting gloves
wherein the scrub person’s
hands remains inside the
sleeves and should not
touch the cuffs
 Gloves – a fitted rubber
material used to cover the
hands before engaging in
surgery
 Points to
 TakeRemember
care not to
contaminate the outside
surface of the glove
 Inserving one self, get
the right glove with your
left hand and the left
glove with your right
hand
 In
serving the gloves,
you must have a wide
base of support by
 Alwaysserve the right
hand glove first
 Always keep gloved
hands at or above the
waist level.
 Alwayskeep glove
hands in sight
 Keepgloved hands
away from your mask
PARTS:
- Palmar surface STERILE SURGICAL
GLOVES
Dorsal surface
Finger holes
Wrist
Cuff
  Open Gloving - is for   Closed Gloving - is
procedures outside the the recommended
operating room (OR) technique for those
and is used when involved in a surgical
preparing for OR procedure.
theater.
 OPEN
GLOVING
 1. Do surgical handwashing

 2. Open the package of the

sterile gloves.
 3. Place the package of the
gloves on a clean dry surface.
 4. some gloves are packed in an
inner as well as an outer
package. Open the outer
package without contaminating
the gloves or the inner package.
 Remove the inner package from
the outer package.
 Openthe inner package as
above or according to the
manufacturer’s directions.
5. Pick up the cuff of the right
glove with your left hand.
Slide your right hand into
the glove until you have a
snug fit over the thumb joint
and knuckles. Your bare left
hand should only touch the
folded cuff – the rest of the
glove remains sterile
6. Slide your right fingertips
into the folded cuff of the
left glove. Pull out the
glove and fit your right
hand into it.
7.Unfold the cuffs down over
your gown sleeves. Make
sure your gloved fingertips
do not touch your bare
forearms or wrists.
CLOSED
GLOVING
 CLOSED
GLOVING
Using the closed-glove technique, put on the sterile gloves.
1. With your left hand still inside the gown, pick up the
folded edge of the right glove.
2. Hold your right hand out, with palm up still inside the
sleeve.
3. Lay the right on the right hand (which is still inside the
sleeve). Position it with the gloved fingers printing
towards the fingertips. The thumb of the glove should be
over the thumb of your right glove.
4. Use your right hand (which is still inside the
sleeve) to grasp the bottom fold of the cuff end of
the right glove.
• You are touching sterile gown to sterile glove.
5. With your left hand ( which is still inside the gown
sleeve), grasp the right glove cuff by the top fold of
the duff end, and pull the right glove cuff up and
over the right gown cuff.
6. Adjust the right glove cuff over the right gown cuff
as necessary, keeping the left hand inside the gown.
7. Work your right hand down into the glove.
• If the fingers are not in place, don’t worry you can
correct them when both gloves are on.
8. Pick up left glove with the gloved right hand.
9. Hold your left hand, palm up, inside the gown sleeve.
10. Place the left glove on the left palm (which is still
inside the gown), with glove fingers pointing toward the
elbow and the cuff end pointing toward your fingertips.
• Position the glove thumb over the left of your hand.
11. Use your left hand (which is still inside the sleeve)
to grasp the bottom fold of the cuff end of the left cuff.
12. Grasp the top of the cuff edge with the gloved
right hand, and pull the glove cuff up and over the
gown cuff.
13. Work your left hand down into the left glove.
14. Turn up and adjust the cuffs of both gloves.
15. Pull the glove fingers out at the ends to reposition
our fingers if necessary.
 Gowning and
Gloving the
Surgeon
 Gowning the Surgeon:

 1. Open hand towel and hold end

part for the Surgeon to grasp the
opposite end of the towel.
 2. Grasp the gown in one hand.
 3. Shake out stretched hands
holding it at the neckband.
 4. offer inside of the gown to the
surgeon.
 5. Release the gown.
 Gloving the Surgeon:
 1. Squeeze lubricant or powder on
the Surgeon’s palm.
 2. Grasp the right glove firmly with
the four fingers under the
tintroduceurned back-cuff.
 3. The palm of the glove should be
facing the surgeon. Stretch the cuff
enough to his hands.
 4. The surgeon place his hand into
the glove. Unfold the turned back cuff
of the glove over his sleeve.
 5. Repeat procedure for the left hand.
 6. Discard wrapper into the waste
container.
 PROCEDURES: please refer to your RLE MANUAL
 Links: Link:
https://chicago.medicine.uic.edu/wp-content/uploads/sites/6/2017/06/UIC-Gowning-Glo
ving.pdf
 Pictures taken from:
 Geekymedics.com
 Dreamstime
 Youtube image from TiHoVideos
 Surgical Nurse Stock Vectors, Clipart and Illustrations
 RCOG eLearning
 mvclasses.com
 indiaMART
 Favpng.com
 Nurses.labs.com
 Country living magazine
 123RF.com
 eLearning.com
 pngfuel.com
 Proper Donning of
Personal Protective Equipment (PPE)
Key points to remember:
Don PPE before patient contact and generally before
entering the patient room.
Once it is on, use PPE carefully to avoid contamination.
General Safe-work Practices
Keep your hands away from the face.
Work from clean to dirty.
Avoid touching areas in the patient’s room.
Change PPE when torn or contaminated.
Additional PPEs for certain cases
Surgical Cap or Head Cover- used during surgery
and outbreaks of Viral Hemorrhagic Fever (VHF) or
Ebola Virus Disease (EVD).
Shoe Cover – used in the surgical area and prevent
contamination of shoes with blood and body fluids.
Apron– used together with a gown that is not fluid-
resistant.
Coverall-used for highly infectious disease (e.g.
VHF or EVD)

1 Perform hand hygiene 5 Don goggle or face shield

Wash hands with soap and water, or use an Place over face and eyes and adjust to fit.
alcohol-based sanitizer.

2 Don shoe cover 6 Don bonnet

Don your shoe covers. Make sure that all
areas of the foot are covered and the shoe
5Place over face and eyes and adjust to fit.

covers are snug over your ankle and calf.

3 Don the gown 7 Don gloves

Fully cover torso from neck to knees, arms to Extend to cover the wrist of two (2) isolation
the end of wrists, and wrap around the back gloves.

4 Don the mask

Secure elastic bands in the middle of the
head and back.
Fit flexible band to the nose bridge.
Fit snug to face and below the chin.
 Proper Doffing of
Personal Protective Equipment (PPE)
Key points to remember:
Remove all PPE except respirator mask at patient’s
doorway or anteroom.
Remove mask outside of room after closing the patient’s
door.
If hands become contaminated during PPE removal, stop
and perform hand hygiene, and then produced with PPE
removal.
General Safe-work Practices
Keep your hands away from the face.
Work from clean to dirty.
Avoid touching areas in the patient’s room.
Change PPE when torn or contaminated.
1 Doff shoe cover
Grasp the outside of the shoe cover and pull
down toward your ankle. Then, lift the shoe
cover over your heel, pull it off your foot, and
dispose of it correctly.
2 Perform hand hygiene
Remove first layer of gloves and sanitize
hands with alcohol-based sanitizer.
3 Doff face shield
Remove face shield by its side.
Doff the gown together with
4 clean gloves
Unfasten gown ties and pull gown away from
neck and shoulders, touching inside of gown
only. Turn gown inside out, and roll into a
bundle a discard in a waste container.
Additional PPEs for certain cases
Surgical Cap or Head Cover- used during surgery
and outbreaks of Viral Hemorrhagic Fever (VHF) or
Ebola Virus Disease (EVD).
Shoe Cover – used in the surgical area and prevent
contamination of shoes with blood and body fluids.
Apron– used together with a gown that is not fluid-
resistant.
Coverall-used for highly infectious disease (e.g.
VHF or EVD)
5 Doff bonnet
Remove from inner back to front, make sure
not to touch the outside layer of the bonnet.
6 Doff goggle or the face shield
Remove goggles or face shield from the
back by lifting headband or earpiece.
7 Doff the mask
Grasp the elastics of the mask, and remove
without touching the front. Discard after use.
8 Perform hand hygiene
Wash hands with soap and water, or use an
alcohol-based sanitizer.
Documentation
And
Reporting
General Objectives:

After the discussion the BSN 2

students will able to develop
positive attitude, acquire basic
knowledge and skills in Proper
Documentation and Reporting.
Specifics Objectives:

The BSN 2 students will be able to:

1. Familiarize the forms inside the
Patient's chart accordingly.
2. Know the importance of
Documentation and Report as a
mean of communication and
indicator for quality care.
3. Know how to label the Patients
kardex correctly.
4. Formulate Nursing Care Plan and
discharge plan base on the
patients fhealth needs.
 Documentation

● It serves as a permanent record of client

information and care.

● A legal, written evidence of the interactions

between and among health professionals,
clients, their families, and health care
organizations.
Reporting ● It is oral, written or computer based
communication intended to convey
information.

● Takes place when two or more people

share information about client care,
either face to face or by telephone.
Introduction
All professional Since nursing Each health care
persons need to has been organization has
be accountable considered as policies about
for the profession, recording and
performance of nurses need to reporting
their duties to record their clientdata, and
the public. work on each nurse is
completion. accountable for
practicing
according to
these standards.
Guidelines for ❏ Based on fact, correct and
consistent.

Documentation ❏ Be written as soon as possible after

an event has happened.
❏ Be written clearly and in such a way
that the text cannot be erased.
❏ Be written in such a way that any
alterations or additions are dated,
timed and signed, so that the
original entry is still clear.
❏ Be accurately dated, timed and
signed, with the signature printed
alongside the first entry.
❏ Be readable on any photocopies.
Purposes of ❏ Report is an essential tool for

Report
communication.
❏ To show the kind and amount of
services rendered over a specific
period.
❏ To illustrate progress in teaching
goals.
❏ As an aid in studying health
conditions.
❏ As an aid in planning.
❏ To interpret the services to the
public and to the other interested
agencies.
CRITERIA FOR A GOOD REPORT
❏ Made promptly.
❏ Clear, concise, and complete.
❏ It is clearly stated and well organized.
❏ Important points are emphasized.
❏ In case of oral reports they are clearly
expressed and presented in an
interesting manner.
CHARTING
- objective, not subjective.

- if it wasn't charted, it wasn't done.

- charting should include assessment,

intervention, and patient response.
• -Charting should occur when a patient is
transferred - before, during, and after - to
another unit in the facility, or to and from
another facility.

-It should also occur for discharge

planning and discharge instructions.
Types of Charting

1. Narrative notes
2. Charting by exemption
3. SOAPIER notes
4. PIE Charting
5. Focus (DAR) Charting
1. Narrative Charting
Date Time Progress Notes
11/15/2013 0815 Assessment performed,
resident with C/O SOB,
states, “I just can’t seem to
Example: catch my breath, and I am
coughing up green
Treatment Chart phlegm.” On auscultation,
breath sounds decreased
Admission sheet in bases bilaterally, coarse
rhonchi bilaterally in upper
Initial Nursing Assessment lobes, accessory muscle
Graphic Record use noted bilaterally,
breathing is shallow and
lips are cyanotic. Vital signs
assessed; temp: 100.5, BP:
110/76, HR: 108, RR: 32,
SpO2: 95% on room air.
‐‐‐‐‐‐ J.Smith, RN
0820 Assessment findings
reported to Dr. Halifax ‐‐‐‐ J.
Smith, RN
0825 Resident assessed by Dr.
2. Charting by Exception

• Additional treatments
done or planned
treatment withheld
• New concerns
• Changes in patient
condition
3. SOAP(IER) Notes

SOAP(IER) stands for “subjective,” “objective,”

“assessment,” and “plan,” with some nurses
choosing also to add “intervention,”
“evaluation,” and “revision.”
 Example: SOAP(IER)
Date Time Progress Notes

05/01/2012 1730 S - Pt: “I don’t feel well.”

O - Temperature 102.4°F

A - Fever

P - Offered extra fluids, monitor body temperature

I - 750mL of fluid intake in 8 hours; assess temperature every 4 hours

‐‐‐‐‐‐ J.Doe, RN

2135 E-Temperature reduced to 101°F

R-Increase fluid intake to 1000mL per shift until temperature is less than 100°F

‐‐‐‐‐‐ J.Doe, RN
4. PIE Charting
Similar to SOAP(IER), PIE is a simple acronym you
can use to document specific problems (P), as
well as their related interventions (I) and
evaluations (E).
Date Time Progress Notes

02/01/2008 1320 P#1 - Risk of aspiration secondary decreased level of consciousness.

I#1 - Head of bed elevated 45 degrees while eating and for one hour after eating.
Liquids thickened and fluids given with straw. Dr. B. Jones notified. Ativan DC’d.

‐‐‐‐‐‐ B. Moore, RN

1500 E#1 - No aspiration. Client alert and responsive. ‐‐‐‐‐‐ B. Moore, RN

5. Focus (DAR) Charting
- Focus charting uses the DAR process (i.e., “data,” “action,” “response”) to
guide and organize nursing notes.
Date Time Focus Progress Notes

02/01/2008 1320 Fever D: Temperature 102°F orally. Face flushed. Frontal headache (2 on a 0-10
pain scale).

A: Acetaminophen 500mg orally. Cool compress to forehead. 400ml apple

juice. Recheck temperature in 1 hour. --------- M. Brown, RN

1420 Fever R: Temperature 99.8°F orally. Face remains slightly flushed. No headache. ---
------ M. Brown, RN
Types of forms
inside Patient
Chart
Internship Report
Kardex is a series of flip cards and it originates in the unit to
which the patient is admitted.

➢ Upon admission the Nurses writes all the information of

the patient on the kardex like Like Personal Data,
Physicians orders,Medications,treatment,Procedures,
IVs,Laboratory,Allergies, and Diet.
➢ Kardex should be used as means of communication
between shifts and nurses and used at the handover of
shifts.
➢ Kardex is updated with each change of orders.
Nursing Kardex
Graphing Vital Signs
❏ The first set of clinical
examinations is an evaluation of
the vital signs of the patients.

❏ The vital signs consist of

temperature, pulse rate, blood
pressure, and respiratory rate.
❏ Healthcare providers must
understand the various
physiologic and pathologic
processes affecting these sets of
measurements and their proper
interpretation.
Transcribing Doctor’s Order
❏ An order (written or verbal) made by
the physician pertaining care or
management of the patients.

❏ Transcribe medical order

accurately to nursing kardex ,fill it

up if it's under medication sheets,
also in appropriate forms for
laboratory and diagnostics.
❏ If in doubt, ask the Doctors if you
can't read the orders.
❏ New orders must be written on the
date and time of order.
❏ Don't forget to let the Physician sign
his orders.
❏ Recheck your transcription word for
word to make sure that it was
transcribed correctly.
 Formulating
Nursing Care Plan
& Discharge Plan
● A written plan of actions or an
outline of the care that the
nurses provide to their patients.

● It is important because it is
means of communication
between one nursing staff to the
other, especially during shift

changes and endorsements.

 Step 1: Assessment
About collecting and collating all related patient information in order to create a sound
nursing diagnosis.The Assessment phase is divided into two Groups:

1. Subjective- Are dependent on patients thoughts,actions, and feelings. Usually

composed:
❏ Patient’s Verbalization / Chief complaint, e.g. “ My stomach is so painful.”
❏ Pain level on a 0 to 10 scale with 10 being the highest and 0 being the lowest
❏ Behavior, e.g. refusal to eat; guarding sign on the affected area-Feelings, e.g. “I'm
stressed with these watery stools.”
❏ Perceptions, e.g. “ I Think I am not taking the anti-diarrheal drug properly.”
Objective data are based on measurable aspects of the condition of the patient,
such as :

-Vital Signs and general appearance

-Diagnostic test results
-Physical examination, e.g. cold, clammy skin, capillary refill of 4 seconds
-Assessment tools, e.g. type 6 watery stools based on the Bristol tool chart

★ It is important to note that all the data that you will put in the Assessment
section of your nursing care plan are precise, brief, and are all able to support
your nursing diagnosis.
Step 2: Diagnosis
A Nursing Diagnosis summarizes all the relevant patient data into one
statement that answers the question. “What is the problem with the patient?”.
This directs the nurse to the type and level of care that the patient requires.

➔ The formula of a nursing diagnosis is :

Diagnostic label + Related or secondary factor + Evidence = Nursing

Diagnosis

➔ Related factor : “Related to pneumonia”

➔ Evidence: “as evidenced by productive cough, shortness of breath,

oxygen saturation at 91% on room air”
Step 3: Planning

The Planning section involves your goals or desired outcomes to resolve the nursing diagnosis or the patient’s
problem.

➔ The desired outcomes can be divided into long-term goals and short-term goals.

➔ Long-term goal for Ineffective Airway Clearance is: “The patient will maintain a patent airway.”

➔ Short-term goals can be: “Within 4 hours, the patient will have an oxygen saturation of at least 96% on room
air.”

➔ Each goal should SMART: short and specific, measurable, achievable, realistic, and time-bound.
Step 4: Intervention
The Nursing Interventions involves the nursing actions include what and
when to assess and monitor in terms of a patient's vital signs and diagnostics,
the nursing actions required (e.g. medication, suctioning, oxygen therapy)
fluid and dietary requirements, mobility, as well as the patient's education.

➔ Each nursing intervention should be precise.

➔ For example:
Intervention: Administer supplemental oxygen, as prescribed.
Discontinue if SpO2 level is above the target range, or as ordered by the
physician.

➔ Rationale: To increase the oxygen level and achieve an SpO2 value

within the target range.
Step 5: Evaluation Evaluation is the final step in a nursing care plan where
you can set parameters to check if the desired outcomes
and goals are fully met, partially met, or unmet.

➔ This shows whether the nursing actions are

effective, need modifications, or required to be
stopped and changed.

➔ If a goal is partially met or unmet, then it is crucial

to re-visit the nursing diagnosis, re-think about the
goals, and change some of the nursing
interventions.

➔ Here’s an example:

Evaluation:
Goal met, as evidenced by patient’s increase of
saturation levels from 92% to 96% on room air.
Nursing Progress Notes

Nurses’ notes are part of charting.

These notes are the formal documentation that

nurses make when charting like write all what
care you provided to the patient during patients
visit.
MEDICATION ADMINISTRATION
General Objective:
After the discussion
and demonstration,
the BSN 2 students
will able to develop
positive attitude,
acquire basic
knowledge and skills
in medication
administration.
Specific Objectives:
 Recognize the importance of following the Twelve
SPECIFIC OBJECTIVES:
Rights in administering medication strictly
 Define related terms correctly
 Calculate medication dosage accurately.
 Practice the procedure at home following the steps
written in RLE Manual.
 Prepare the materials needed inn medication
administration before the procedure.
 Return demonstrate medication administration
utilizing the correct steps written in RLE Manual.
DEFINITION OF
TERMS
 Physician -
legally
responsible for
prescribing
medications
Medication - a
substance
administered
for diagnosis,
cure,
treatment,
relief or
prevention of
disease. It is
also called
drug.
 Medication
Administration -
task of a nurse; a
nursing
dependent action;
an important
nursing function
that involves
skillful technique
and consideration
of the patient’s
development and
safety.
• Pharmacology
- is the study
of the effect of
drugs on living
organisms.
Pharmacy – is the art of preparing, compounding and
dispensing drugs; refers to the place where drugs
are prepared and dispensed.
 Pharmacist –
a licensed person to
prepare and
dispense drugs
and to make up
prescriptions.
 PRESCRIPTION -
the written direction
for the preparation
and administration
of a drug.
 Pharmacopoeia – is a book containing a list of
products used in medicine, with descriptions
of the product chemical tests for determining
identity and purity and formulas for certain
mixtures.
Formulary – is a collection of formulas and
prescriptions.
 • Pharmacodynamics – the
process by which drugs alter
the cell physiology and cause
the effects on the body

• Pharmacokinetics – the study

of the action in the body and
their movement though the
body systems during
absorption, distribution,
biotransformation and
elimination, including the
time required for therapeutic
or pharmacological response
to them.
• Pharmacoanthropology
– science that deals with
the study of the
difference in the drug
response in various ethic
or racial groups.

• Posology - the study of

dosage or amount of
drugs given in the
treatment of diseases
Drug Study/Summary
– study of drugs
before giving
medications
• Generic Name- given
before a drug becomes
official. Reflects the
chemical family to which
the drug belongs (e.g.
Acetaminophen for
Tylenol, Paracetamol for
Biogesic , Ibuprofen for
Advil)

• Official Name- the name

under which it is listed in
one of the official
publications.
• Chemical Name -the name
by which a chemist names it;
this name describes the
constituents the drug
precisely (e.g acetyl-para-
aminophenol for Tylenol)

• Trade Name/Brand Name-

the name under which a
manufacturer market the
medication (e.g.Tylenol.
Biogesic, Advil)
 • Nurse -
person
licensed to
administer,
educate
about, and
evaluate the
effectiveness
of prescribed
medications.
 DIFFERENT
SKILLS REQUIRED
IN THE
ADMINISTRATION
OF MEDICATIONS
1.COGNITIVE SKILLS -
What to do; how to
implement or execute
orders or
interventions

2.TECHNICAL SKILLS –
handling situations;
palpation techniques,
use of equivalents;
technicalities
3. INTERPERSONAL SKILLS -
What they are, how to
improve them and how
to apply them

4. ETHICAL AND LEGAL

SKILLS- medical ethics
involves examining a
specific problem, usually
a clinical case, and using
values, facts, and logic to
decide what the best
course of action should
be.
 SOURCES OF DRUG INFORMATION
1. PIMS (Phil. Index for Medical 6. Journals
Specialists)

2. MIMS (Medical Index for 7. Nursing Drug Handbook

Medical Specialists)

3. PDR (Physician Drug Reference) 8. Package insert of the drug

4. Pharmacology book 9. The physician who prescribes

the drug

5. RN magazines and Medical

magazines
4 KINDS OF DRUG NAME/DRUG NOMENCLATURE
A. Prescription Name/
Generic Name – the
name given to a
drug before it
becomes official. It
refers to the
chemical make up of
a drug rather than
to the advertised
brand name under
which the drug is
sold . It refers to any
drug marketed
under its chemical
name.
B. Official Name –
the name after
which the drug is
listed in one of
the official
publications like
the BFAD; the
generic name is
usually followed.
C. Chemical Name – the name which describes the
constituents of drugs precisely; used is the chemical
name with the highest constituent of the drug; chemical
composition; very significant to the pharmacist.

D. Brand Name – the name given to a drug by the

manufacturer. It is also called trademark.
PHARMACOKINETIC
vs.
PHARMACODYNAMIC
PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTION

A
D
M
E
A -BSORPTION
D -ISTRIBUTION
M -ETABOLISM
E -XCRETION
Pharmacokinetics

Route: how enter the

body
• Absorption: from site
into blood
• Distribution: from
blood into cells,
tissues, or organs
Action: how a
medication acts
• Metabolism: changed
to prepare for excretion
• Excretion: how they
exit the body
Pharmacodynamics

The process by which a

drug changes the body.
Such changes require
that the drug interact
with specific molecules
and chemicals normally
found in the body.
Effects of Drugs
 • Therapeutic Effect/
Desired effect :
expected or predicted
physiological response
that a medication causes .
It is the primary effect
intended, that is the
reason the drug is
prescribed.
• Side effect: predictable
and often unavoidable
secondary effects
produced at a usual
therapeutic dose

• Adverse effect:
unintended, undesirable,
and often unpredictable
severe responses to
medication
• Toxic effect: develop
after prolonged intake of
a medication or when a
medication accumulates
in the blood because of
impaired metabolism or
excretion.
• Idiosyncratic effect:
Unpredictable. A patient
overreacts or under
reacts to a medication or
has a reaction different
from normal.
 DRUG TOXICITY :
Deleterious or dangerous effects of a drug on an
organism or tissue. Results from over dosage or
ingestion of a drug intended for external use and
buildup of the drug in the blood because of
impaired metabolism or excretion (cumulative
effect). 
 Drug Tolerance :
Exists in a person who has unusually low
physiologic response to a drug and who requires
increases dosage to maintain a given therapeutic
effect.
 Drug Interaction:
Occurs when the administration of one drug
before, at the same time as, or after another
drug alters the effect of one or both drugs.
 CUMULATIVE EFFECT :
It is the increasing response to the repeated doses of
drug that occurs when the rate of administration
exceeds the rate of metabolism or excretion and
produces TOXICITY.
 Iatrogenic Disease:
Disease cause unintentionally by medical therapy or
can be due to drug therapy. Hepatic toxicity
resulting in biliary obstruction, renal damage and
malformations of fetus as a result of specific drugs
taken during pregnancy are examples.
Drug Misuse
 Drug Abuse – inappropriate intake of a substance,
either continually or periodically.

 Drug Dependence – it is a person’s reliance to take a

drug or substance. Intense physical or emotional
disturbance is produced if the drug is withdrawn
 Addiction – it is due to biochemical changes in body
tissues, especially the nervous system. These tissues
come to require the substance for normal
functioning. Also called physical dependence.
 Drug Habituation – it is the emotional reliance on a
drug to maintain a sense of well being accompanied
by feelings of need or cravings for the drug. It is also
called psychological dependence.
 Illicit Drugs:
(Street Drugs), are those sold illegally.
2 Types of Illicit Drugs
 Drugs unavailable for purchase under any circumstances
 Drugs normally available with a prescription that are being
obtained through illegal channels.

*Often taken because of their mood altering effect,

the person feel relax and happy.
Allergic Responses
• Allergic reaction
Unpredictable.
Repeated
administration the
patient develops
an allergic
response to it, its
chemical
preservatives, or a
metabolite.
The immunologic or
anaphylactic
reaction to the
drug. Can occur
anytime from a
few minutes to 2
weeks after the
administration of
the drug. Allergic
or adverse
reaction can either
be mild or severe.
1. Mild – occurs anytime
from few hours to 2
weeks after the
administration of the
drug

Examples:
• Skin rash (urticaria) –
generalized;
intraepidermal vesicle
rash or a rash typified
by an urticarial wheal
or macular eruption
Pruritus – itching
of the skin with
or without rash
Angioedema – due to
increased
permeability of blood
capillaries
• Rhinitis –
excessive
watery
discharge
from the nose
• Lacrimal tearing
– excessive
tearing

• Nausea and
Vomiting –
stimulation of
the center of
the brain
 • Wheezing and
Dyspnea – shortness
of breath and
wheezing upon
inhalation &
exhalation due to
accumulated fluids
& swelling of the
respiratory tissues
• Diarrhea –
irritation of the
mucosa of the
large intestine
 2. SEVERE – usually
occurs immediately
after the
administration of the
drug.

Anaphylactic reaction – a
severe allergic reaction
which usually occurs
immediately following
administration of the
drug; life-threatening
Symptoms: (SAT)
Shortness of breath
Acute hypotension
Tachycardia
Therapeutic
Action of
Drugs
DRUG TYPE DESCRIPTION EXAMPLES

PALLIATIVE Relieves the Morphine sulfate,

symptoms of a Aspirin for Pain,
disease but does not
affect the disease
itself.
CURATIVE Cures a disease or Penicillin for infection
condition
SUPPORTIVE Supports body Norepinephrine
function until other bitartrate for low
treatments or the blood pressure,
body’s response can Aspirin for high body
take over temperature.
 DRUG TYPE DESCRIPTION EXAMPLES

SUBSTITUTIVE Replaces body fluids Thyroxine for

or substances hypothyroidism

Insulin for diabetes

mellitus

CHEMOTHERAPEUTIC Destroys the Busulfan for

malignant cells Leukemia

RESTORATIVE Returns the body to Vitamins,

health Mineral supplements
Medication: Forms
• Tablet –
compressed
powder
Enteric coated – dissolves in small intestine
• Time release – granules with different
coatings, or some tablets that dissolve slowly
• Elixir – mixed with water or alcohol and a
sweetener
• Syrup – Medication dissolved
in a sugar solution
• Suspension – drug particles in a liquid medium;
when left alone will settle in the
bottom

• Solution – Sterile preparation that contains

water and one or more dissolved compounds
(IM, SQ, or IV)
• Paste – semisolid, but thicker than ointment –
slower absorption

• Transdermal disk or patch – semi-permeable

membrane disk or patch with drug applied to skin
• Lotion – liquid suspension for skin

• Ointment – semisolid
• Suppository – solid drug mixed with gelatin
inserted into body cavity to melt (rectum or
vagina)
 Types
of
Doctor’s
Order
 MEDICATION ORDERS
A medication order is a written
directions provided by a
prescribing practitioner for a
specific medication to be
administered to an individual.
The prescribing practitioner
may also give a medication
order verbally to a licensed
person such as a pharmacist or
a nurse.
1. Standing order – it is carried
out until the specified period
of time or until it is
discontinued by another order;
it may or may have a
termination date
E.g.: Demerol 100 mg 1 M every
4 hrs x 5 days
2. Single order – it is carried out
for one time only; is for
medication to be given a
specified time
E,g.: Seconal 100 mg hs before
surgery
3. STAT order – it is carried out
at once or immediately
E.g.: Demerol 100 mg IM STAT
4. PRN order – it is carried
out as the patient requires
E.g.: Calcibloc 5 mg PRN 
 7 ESSENTIAL
PARTS
OF A DRUG ORDER
1. Client’s full name –
the first and last
names , middle
initials or names
should always be
used to avoid
confusions between
two clients who have
the same last name.
Client’s identification
number , room
number and
provider’s name for
further identification.
2. Date and time
the order is
written – the
day the month
and the year
the order is
written .
3. The name of the
drug to be
administered –
must be clearly
written . In some
settings only
generic names are
permitted,
however trade
names are widely
used in hospital
and health
agencies.
4. The dosage
of the drug –
includes the
name of the
drug,
route ,amou
nt , and the
time.
5. Frequency of
administration -
and in many
instances the
strength; for
example
tetracycline
250mg (amount)
four times a day
(frequency).
 6. Route of
administration
– this part of the
order like other
parts is frequently
abbreviated . It is
not unusual for a
drug to have
several possible
routes of
administration ,
therefore, it is
important that the
route be included
in the order.
7. Signature of
the primary
care providers
– makes the
drug order a
legal request.
3 STEPS IN PATIENT’S MEDICAL ORDER

1. Medication ticket
2. Medication sheet
3. Nursing Kardex
 PARTS
OF
A
PRESCRIPTION
 1. Name of the
( Doctor, Hospital or
Clinic)

2. Descriptive
information about
the client (Name,
address, age)
3. Date on which the
prescription was
written
4. The Rx symbol
meaning “take thou”
5. Medication name,
dosage and strength
6. Dispensing
instructions for the
pharmacist. E.g.:
Dispense 30 capsules
 7. Directions for
administration to be
given to the client.

8. Refill and or special

labeling

*1. Prescriber’s
signature
 Medication
Abbreviations
ANST After negative skin test

PRN As needed, as necessary

NPO Nothing per orem (nil per

os)
BID Twice a day

OD Once a day

TID Three times a day

QID Four times a day

ad lib As desired

ac Before meals (ante cebum)

pc After meals (post-cebum)

RTC Round the clock

HS Hour of sleep

QHS Every bedtime

HGT Hemoglucose Testing

OS Left eye
AS Left ear
AD Right ear
OD Right eye
OU Both eyes
AU Both ears
Rx Prescribe/ Take Thou
Tx Treatment
@ at
Ṫ 1 (one)
STAT Immediately
SQ subcutaneous
IM Intramuscular
ID Intradermal
mL Millilitre
mg Milligram
gtts drops
Tsp Teaspoon
Tbsp Tablespoon
q 4H Every 4 Hours
qH Every Hour
OZ Ounce
Lbs Pounds
qt quart
 KVO Keep Vein Open
KSS Keep Set Sterile
FBC to UB Foley Bag Catheter to
Urobag
CBR with TP Complete bed Rest with
Toilet Privilege
D/C Discharge, Discontinue

ISA Injection site adaptor

DAT Diet as Tolerated
Ten Rights
of
Medication
 MR. ED TRACED
M- Medication R- Refuse

R- Route A- Assessment

E- Education C- Client

D- Dosage E- Evaluation

T- Time D- Documentation
 1. RIGHT MEDICATION

The medication given was the medication ordered.

 2. RIGHT ROUTE
Give the medication by the ordered route.
Make certain that the route is safe and
appropriate for the client.
3. RIGHT EDUCATION
• Explain information about the medication to the
client (ex. Why receiving, what to expect, any
precautions)
 4. RIGHT DOSE
The dose ordered is appropriate to the client. Give
special attention if the calculation indicates multiple
pills/tablets or a large quantity of a liquid medication.
This can be an indication that calculation is incorrect.
Double check calculation that may appear
questionable.
Know the usual dosage range of the medication.
Question a dose outside of the usual dosage range.
 5. RIGHT TIME

Give the medication at the right frequency and

at the time ordered according to agency policy.
 6.RIGHT TO REFUSE
• Adult client has the right to refuse any medication.
• The nurse’s role is to ensure that the client is fully informed
of the potential consequences of refusal and to
communicate the client’s refusal to the healthcare provider.
 7.RIGHT ASSESSMENT
 Some medications require specific assessments
prior to administration
 Medication orders may include specific parameters
for administration
 8.RIGHT CLIENT
Medication is given to the intended client.
Check the client’s identification band with each
administration of a medication.
Know the agency’s name alert procedure when client’s with
the same or similar last names are on the nursing unit.
 9. RIGHT EVALUATION
Conduct appropriate follow up
Ex. Was the desired affect achieved or not?
Did the client experience any side effects or
adverse reactions?
 10.RIGHT
DOCUMENTATION
• Document medication
administration after
giving it , not before.
• If time of administration
differs from prescribed
time , note the time in
the MAR and explain
the reason and follow
up through activities.
• If the medication is not
given, follow the
agency’s policy for
documenting the reason
why.
Medication:
Nurse Role
 Follow 10 rights
 Read labels 3x
 Use at least 2 patient
identifiers
 Avoid interruption
 Double check calculations,
verify with another RN,
follow policy
 Question unusual doses
 Record after medication
given
 Report errors, near-
misses
 Participate in programs
designed to reduce error
 Patient education about
medications
Because nurses play
an essential role in
preparing and
administering
medications, they
need to be vigilant in
preventing errors.
 Regardless of how the
nurse receives a
medication order, he or
she compares the
prescriber’s written orders
with the medication
administration record
(MAR) or the electronic
medication administration
record (eMAR) when
medication is initially
ordered.
When performing
medication
calculations or
conversions, have
another qualified
nurse check the
calculated doses.
An important step in
safe medication
administration is
making sure that you
give the right
medication to the
right patient. Before
administering a
medication, use at
least two patient
identifiers.
 Always consult the
prescriber if an order
does not designate a
route of administration.
Likewise, if the
specified route is not
the recommended
route, alert the
prescriber immediately.
 You need to
know why a
medication is
ordered for
certain times of
the day, and
whether you are
able to alter the
time schedule.
 A
medication
order is
required
for every
medication
that you
administer
to a
patient.
 Never
document
that you
have given
a
medication
until you
have
actually
given it.
If any question
arises about a
medication
order because
it is
incomplete,
illegible,
vague, or not
understood,
contact the
prescribing
health care
provider
before
administering
the
medication.
Medication Errors
• Report all
medication errors.
• Patient safety is top
priority when an
error occurs.
• Documentation is
required.
• The nurse is
responsible for
preparing a written
occurrence or incident
report: an accurate,
factual description of
what occurred and
what was done.
• Nurses play an
essential role in
medication
reconciliation.
A medication error
can cause or
lead to
inappropriate
medication use
or patient harm.
 Errors include
inaccurate
prescribing or
administration, or
giving a drug via the
wrong route or
frequency.
It is important to
feel comfortable
in reporting an
error and not fear
repercussions
from managerial
staff.
Even when a patient suffers no harm from a
medication error, the institution can still
learn why the mistake occurred and what
can be done to avoid similar errors in the
future.
When an error occurs,
the nurse first
assesses and
examines the patient’s
condition and notifies
the health care
provider of the
incident as soon as
possible.
Once the patient is
stable, the nurse
reports the incident to
the appropriate
person in the
institution (e.g.,
manager, supervisor).
 The nurse is
responsible for
preparing a written
occurrence or
incident report that
usually needs to be
filed within 24 hours
of the error.
 The report includes patient identification
information; the location and time of the
incident; an accurate, factual description of
what occurred and what was done; and the
signature of the nurse involved.
 The occurrence
report is not a
permanent part of
the medical record
and is not referred
to anywhere in the
record.
This legally protects the
nurse and the institution.
Agencies use
occurrence reports to
track incident patterns
and initiate quality
improvement programs
as needed.

Nurses play an essential

role in medication
reconciliation.
Whenever a nurse
admits a patient to a
health care setting,
he or she compares
the medications that
the patient took in the
previous setting (e.g.,
home, another
nursing unit) with his
or her current
medication orders.
When the patient
leaves that setting
for another setting
(e.g., skilled care
facility, intensive
care unit), the
nurse
communicates the
patient’s current
medications to the
health care
providers in the
new setting.
The nurse also
reconciles the
patient’s
medications
when he or she
is discharged
from an agency
or is seen in an
outpatient
setting.
• Many agencies have
computerized or
written forms to
facilitate the process
of medication
reconciliation.
• Advances in
technology have
helped to decrease
the occurrence of
medication errors.
Medication Errors: How does it happen?
 Inaccurate prescribing
 Giving the wrong
medication
 Using the wrong route
 Giving at the wrong time
 Extra doses
 Omission of scheduled dose
 Similar drug names (25%)
 CeFAZolin vs. CefTRIAXone
 Limit verbal orders; follow all procedures
 Use only approved abbreviations, symbols
 OK to question, clarify, repeat
 Occurrence report for errors: nurse’s
responsibility, MD informed, within 24 hours,
reflect, context, identify factors
 Caution with transfers within and between
facilities
Medication: Error Prevention

Checking
compatibility charts
Checking kidney or
liver function &
allergies
Never administer
drugs prepared or
documented by
others
 Never leave meds at
bedside
 Open med at
bedside – check
medication sheet
with ID band
 Some drugs require
2 nurses to check
(insulin, heparin,
etc.)
 Check expiration
dates
 Equivalents
of
Measurements
SYSTEMS OF MEASUREMENT

 METRIC SYSTEM
 APOTHECARIES’
SYSTEM
 HOUSEHOLD SYSTEM
METRIC SYSTEM

Devised by the French in the

latter part of the 18th century ,
is the system prescribed by law
in most European countries and
in Canada.
 Basic units of measurements are the
meter, the liter, and the gram. Only the
measurements of volume (liter) and
weight (gram) are discussed because
these are the measures used in
medication administration.
Apothecaries’ System

It was brought to the United States from

England during the colonial period. The
basic unit of weight in apothecaries’
system is the grain (gr) and the basic unit
of volume is minims, a volume of water,
which means “the least”.
The other units of weight are the dram,
scruple, the ounce, pound. The units of
volume are the fluid dram, the fluid ounce,
the pint, the quart, and the gallon.
Household System

Included in household measures are

drops, teaspoons, tablespoons, cups,
and glasses.
 METRIC APOTHECARY HOUSEHOLD

1mL 15 –16 minims 15 drops (gtt)

5mL 1 dram 1 teaspoon (tsp)

15mL 4 drams 1 tablespoon (tbsp)

30mL 1 fluid ounce 2 tablespoon

240mL 8 fluid ounce 1 cup

480 mL (approx.500mL) 1 pint (pt) 1 pint (pt)

960 mL (approx 1L) 1 quart (qt) 1 quart (qt)

3840 mL ( approx. 4L) 1 gallon (gal) 1 gallon (gal)

 COMMON CONVERSIONS
1Liter 1 000 mL

1 gram 1 000 mg

1 milligram 1 000 mcg

1kilogram 2.2 lbs

1 000 mg or 1 gm
1 000 000 mcg
 ROUTES
OF
ADMINISTRATION
 Oral
The drug is swallowed. It is
the most common , and
most convenient route for
most clients because the
skin is not broken as it is for
an injection . It’s a safe
method.
 Advantages:
safest; most
convenient; safe;
does not break skin
barrier;
administration
usually does not
cause stress
Disadvantages:
slower acting; drug
may have an
unpleasant taste or
odor; drug may
damage & discolor
teeth; drug can be
aspirated by seriously
ill patient; may irritate
gastric mucosa
• SUBLINGUAL ROUTE – Drug placed under the
tongue
Advantage: Drug is rapidly absorbed into the
bloodstream
-medication should not be swallowed
-drug can be administered by local effects
- Ensures greater potency because drugs
directly enters the blood and bypasses the
liver

Disadvantage: If swallowed, drug may be

inactivated by gastric juice; drug must remain
under the tongue until dissolved or absorbed.
Sublingual: under tongue
• Buccal - means pertaining to the cheek. A
medication is held in the mouth against the
mucous membranes of the mouth or
systemically when it is swallowed in the saliva.
Advantages: a medication is held in the mouth
against the mucous membranes of the cheek
until the drug dissolves
- drug may act locally on the mucous
membranes of the mouth or systemically
when it is swallowed with the saliva
Disadvantages: if swallowed, drug may be
inactivated by gastric juice; drugs must remain
under the tongue until dissolved and
absorbed.
 Nasogastric tube

• Liquid form
• Dissolve in 15-30
ml warm water
•Flush tube
with 15-30
ml of water
between
medications
•Flush
afterwards
with 30-
60ml
Nasal Instillation
May self-
administer
Check nares for
irritation
Nasal packing for
bleeding and
certain surgeries
may be used-
applied by provider
Topical Medications
Applied to
a circum-
scribed
surface
area of the
body. They
only affect
the area to
which they
are
applied.
• Ear instillation (OTIC)

Structures are very sensitive

to temperature.
Use sterile solutions.
Drainage may indicate
eardrum rupture.
Never occlude the ear canal.
Do not force medication
into an occluded ear canal.
• Skin (Ointment, Cream,
Paste)

Use gloves and applicators.

Use sterile technique if the
patient has an open wound.
Clean skin first—remove
tissue and crusting.
Apply ointments and pastes
evenly.
Follow directions for each
type of medication.
Inhalation
• Administered into the respiratory tract by a
nebulizer or positive pressure breathing
apparatus.
• Aerosol spray, mist, or powder via handheld inhalers;
used for respiratory “rescue” and “maintenance”
– Pressurized metered-dose inhalers (pMDIs)
• Need sufficient hand strength for use
• INTRAOCULAR ROUTE – administered by
applying a clear, flexible, elliptical shaped disk
similar to contact lens to the conjunctival sac
to provide continuous treatment of a disease
as open angle glaucoma.
• Eye instillation
– Avoid the cornea.
– Avoid the eyelids with droppers or tubes to decrease
the risk of infection.
– Use only on the affected eye.
– Never allow a patient to use another patient’s eye
medication.
• Elderly may have
difficulty with drops
• Risk of transmitting
infection from one eye
to the other, do not
touch any part of the
eye with eye applicator
• Apply ointment along
lower eyelid, drops into
conjunctival sac
Vaginal Instillation
Vaginal Instillation

 use gloves
 privacy
 patient may choose to self-administer
 may need pad to collect any drainage.
 • Solid, oval
suppositories
come individually
packaged in foil
wrappers and
sometimes are
stored in the
refrigerator to
prevent them
from melting.
After a suppository is
inserted into the
Give a suppository
vaginal with a gloved hand in
cavity, body
accordance with standard precautions.
temperature causes
Patients often prefer administering their
it to melt and be
own vaginal medications and need
distributed and
privacy.
absorbed.
• Vaginal medications
are available as
suppositories, foam,
jellies, or creams.

• Foam, jellies, and

creams are
administered with an
applicator inserter.
 Because vaginal
medications are often
given to treat infection,
discharge is usually
foul smelling. Follow
aseptic technique, and
offer the patient
frequent opportunities
to maintain perineal
hygiene.
Rectal Instillation
Rectal Instillation

 gloves
 lubricant rounded end to ease administration
 privacy
 patient may choose to self-administer
 may need pad to collect any drainage.
Rectal suppositories are thinner and more bullet
shaped than vaginal suppositories. The
rounded end prevents anal trauma during
insertion.
 Rectal suppositories contain medications that
exert local effects such as promoting
defecation.
 Rectal suppositories are often stored in the
refrigerator until administered. Sometimes it is
necessary to clear the rectum with a small
cleansing enema before inserting a suppository.
Administering Injections
Types of Syringes
Types of syringes are
shown:

A. 5-mL syringe.
B. 3-mL syringe.
C. Tuberculin syringe
D. Insulin syringe
The tuberculin syringe is
calibrated in sixteenths
of a minim and
hundredths of a milliliter
and has a capacity of
1 mL.
Use a tuberculin syringe
to prepare small
amounts of medications.
A tuberculin syringe is
useful when small,
precise doses are
prepared for infants or
young children.
Parts of a Syringe
 Fill a syringe by pulling the plunger outward while the needle
tip remains immersed in the prepared solution. Touch only the
outside of the syringe barrel and the handle of the plunger to
maintain sterility. Avoid letting any unsterile object touch the tip
or inside of the barrel, the hub, the shaft of the plunger, or the
needle.
Parts of the Needle
 A needle has three parts: the hub, which
fits onto the tip of a syringe; the shaft,
which connects to the hub; and the bevel,
or slanted tip.
The tip of a needle, or the bevel, is always
slanted. The bevel creates a narrow slit when
injected into tissue that quickly closes when the
needle is removed to prevent leakage of
medication, blood, or serum.
 Long beveled tips are sharper and
narrower, minimizing discomfort when
entering tissue used for subcutaneous or IM
injection.
 Some needles come packaged in individual
sheaths to allow flexibility in choosing the right
needle for a patient, whereas others are pre-
attached to standard-sized syringes.
Most needles are made of stainless steel, and
all are disposable.
Types of Needles
Choose needle
length according
to the patient’s
size and weight
and the type of
tissue into which
the medication is
to be injected.
A child or a slender
adult generally
requires a shorter
needle. Use longer
needles (1 to 1 1/2
inches) for IM
injections and
shorter needles (3/8
to 5/8 inch) for
subcutaneous
injections.
As the needle gauge
becomes smaller,
the needle diameter
becomes larger. The
selection of a gauge
depends on the
viscosity of fluid to
be injected or
infused.
PARENTERAL
MEDICATIONS
 Defined as other
than through the
PARENTERAL
alimentary or
respiratory tract
that is by needle.
 A. Subcutaneous
(SQ) – into the
subcutaneous
tissue just below
the skin.

B. Intramuscular
(IM) – into the
muscle
C. intradermal
(ID) – into the
dermis , under
the epidermis
 D.
intravenous
(IV) – into a
vein
Intradermal
 15 degree angle
 skin test, dermis layer of the
skin
 Syringe: 1 ml
 Needle gauge: #25, #26, #27
 Vaccines: BCG, TB testing (48
hrs), allergy testing (30
minutes); 0.1 (medication);
0.9 (distilled water)
Criteria for ID site:

 Hairless
 less pigmented area
 less vascularized
 less keratinized
Route for ID injection:
 Inner lower arm
 Upper chest
 Back beneath the scapula
 Used for skin testing (TB,
allergies)
 Slow absorption from dermis
 Skin testing requires the
nurse to be able to clearly see
the injection site for changes.
 Use a tuberculin or small
hypodermic syringe for skin
testing.
 Angle of insertion is 5 to 15
degrees with bevel up.
 A small bleb will form as you
inject; if it does not form, it is
likely the medication is in
subcutaneous tissue, and the
results will be invalid.
 Because these
medications are potent,
they are injected into the
dermis, where blood
supply is reduced and
medication absorption
occurs slowly. Sometimes
patients have a severe
anaphylactic reaction if
the medications enter the
circulation too rapidly.
 Skin testing requires that
the nurse be able to
clearly see the injection
sites for changes in color
and tissue integrity.
 Intradermal sites need to
be lightly pigmented, free
of lesions, and relatively
hairless. The inner
forearm and the upper
back are ideal locations.
 As you inject the
medication, a small bleb
resembling a mosquito
bite appears on the
surface of the skin. If a
bleb does not appear,
or if the site bleeds after
needle withdrawal,
chances are good that
the medication entered
subcutaneous tissues.
In this case, test results
will not be valid.
Intramuscular
 Faster absorption than
subcutaneous route
 Many risks, so verify the
injection is justified
INTRAMUSCULAR ROUTE
–
 injection into the
muscles; 90 degree
angle
 Route for irritating
solutions, potent and
toxic agents, aqueous,
suspension and
solutions in oil
Advantages:
- Pain from irritating drugs is
minimized
- can be administer larger
volume than subcutaneous
- Drug is rapidly absorbed

Disadvantages:
- Breaks skin barrier
- Can be anxiety producing
• Needle
Very obese: 3 inches
Thin: ½ to 1 inch
• Amounts:
Adults: 2 to 5 mL can be
absorbed
Children, older adults,
thin patients: up to 2 mL
Small children and older
infants: up to 1 mL
Smaller infants: up to
0.5 mL
IM Sites:
 Ventrogluteal – gluteus
medius muscle which lies
over the gluteus minimus

 Dorsogluteal – composed
of thick gluteal muscle of
the buttocks
 Rectus femoris – belongs
to the quadriceps muscle
group situated on the
anterior aspect of the thigh

 Deltoid – is found on the

lateral aspect of the upper
arm

 Vastus lateralis – usually

thick and well developed in
both adults and children
 Ventrogluteal

Three Landmarks: Greater Trocanter, Anterior iliac

spine, iliac crest
 The
ventrogluteal
muscle
involves the
gluteus
medius; it is
situated deep
and away
from major
nerves and
blood
vessels.
 This site is the
preferred and safest
site for all adults,
children, and
infants, especially
for medications that
have larger volumes
and are more
viscous and
irritating. The
ventrogluteal site is
recommended for
volumes greater
than 2 mL.
 Locate the
ventrogluteal
muscle by
positioning
the patient in
a supine or
lateral
position.
Flexing the
knee and hip
helps to relax
this muscle.
Place the palm of
your hand over the
greater trochanter
of the patient’s hip
with the wrist
perpendicular to the
femur. Use the right
hand for the left hip,
and use the left
hand for the right
hip.
Point the thumb
toward the
patient’s groin
and the index
finger toward
the anterior
superior iliac
spine; extend
the middle
finger back
along the iliac
crest toward
the buttock.
The index finger,
the middle finger,
and the iliac crest
form a V-shaped
triangle; the
injection site is
the center of the
triangle.
Vastus Lateralis
The vastus lateralis muscle is another
injection site for adults and children.
The muscle is thick
and well developed,
is located on the
anterior lateral
aspect of the thigh,
and extends in an
adult from a
handbreadth above
the knee to a
handbreadth below
the greater
trochanter of the
femur.
Giving intramuscular
injection in vastus
lateralis muscle:
 Use the middle third
of the muscle for
injection. The width
of the muscle
usually extends
from the midline of
the thigh to the
midline of the outer
side of the thigh.
 With young
children or
cachectic
patients, it helps
to grasp the body
of the muscle
during injection
to be sure that
the medication is
deposited in
muscle tissue.
To help relax the
muscle, ask the
patient to lie flat
with the knee
slightly flexed or
in a sitting
position. The
vastus lateralis
site is often used
for infants,
toddlers, and
children.
Deltoid
 Use this site for
small medication
volumes (2 mL or
less). Carefully
assess the condition
of the deltoid
muscle, consult
medication
references for
suitability of the
medication, and
carefully locate the
injection site using
anatomical
landmarks.
Giving intramuscular injection
in deltoid muscle:

 Use this site only for small

medication volumes, when
giving immunizations.
 When other sites are
inaccessible because of
dressings or casts.
 To locate the muscle, fully
expose the patient’s upper
arm and shoulder.
 Do not roll up a tight-fitting
sleeve. Have the patient
relax the arm at the side
and flex the elbow. The
patient may sit, stand, or
lie down.

 Palpate the lower edge of

the acromion process,
which forms the base of a
triangle in line with the
midpoint of the lateral
aspect of the upper arm.
 The injection site is in the
center of the triangle, about
3 to 5 cm (1 to 2 inches)
below the acromion process.

 You can also locate the site

by placing four fingers
across the deltoid muscle,
with the top finger along the
acromion process. The
injection site is then three
fingerwidths below the
acromion process.
Subcutaneous Injections
The diagram indicates sites
recommended for
subcutaneous injections:

 Outer posterior aspect of the

upper arms,
 Abdomen from below the
costal margins to the iliac
crests
Anterior aspects of the
thighs.
 The photo on the
shows
subcutaneous
heparin being
administered in the
abdomen.

The site most

frequently
recommended for
heparin injection is
the abdomen.
The injection site
chosen needs
to be free of
skin lesions,
bony
prominences,
and nerves.
Z-Track Technique
 Z-track method of injection
prevents deposit of
medication into sensitive
tissue. It is recommended
that, when administering IM
injections, the Z-track
method be used to minimize
local skin irritation by sealing
the medication in muscle
tissue. The Z-track method
for IM injections protects
subcutaneous tissues from
irritating parenteral fluids.
 Steps:

1. To use the Z-track method, put a new

needle on the syringe after preparing the
medication, so no solution remains on the
outside needle shaft.
2. Then select an IM site,
preferably in a large, deep
muscle such as the
ventrogluteal muscle. Place
the ulnar side of the
nondominant hand just below
the site, and pull the overlying
skin and subcutaneous
tissues approximately 2.5 to
3.5 cm (1 to 1 1/2 inches)
laterally or downward. Hold
the skin in this position until
you administer the injection.
3. After preparing the site
with an antiseptic swab,
inject the needle deep into
the muscle. Grasp the barrel
of the syringe with the thumb
and index finger of the
nondominant hand, and
slowly inject the medication
at a rate of 10 seconds per
milliliter if no blood return is
noted on aspiration.
 4. The needle remains
inserted for 10 seconds to
allow the medication to
disperse evenly rather than
channeling back up the
track of the needle.
Release the skin after
withdrawing the needle.
This leaves a zigzag path
that seals the needle track
where tissue planes slide
across one another.
The medication cannot escape from the
muscle tissue. Injections using this technique
result in less discomfort and decrease the
occurrence of lesions at the injection site.
Comparison of Angles of Insertion for Injections
Mixing Medications from Two Vials
In (A), the diagram
shows injecting air into
vial A.
B shows injecting air
into vial B and
withdrawing dose.
C diagrams
withdrawing
medication from vial A.
The medications are
now mixed.
 Use only one syringe with a
needle or needleless access
device attached to mix
medications from two vials.
 Aspirate the volume of air
equivalent to the dose of the first
medication.
 Inject the air into vial, making sure
that the needle does not touch the
solution. Withdraw the needle and
aspirate air equivalent to the dose
of the second medication.
Inject the volume of air into vial.
Immediately withdraw the medication
from vial into the syringe and insert
the needle back into vial, being
careful not to push the plunger and
expel the medication within the
syringe into the vial.

Withdraw the desired amount of

medication from vial A into the
syringe .
After withdrawing the
necessary amount, withdraw
the needle and apply a new
safety needle or needleless
access device suitable for
injection.
Drug computation

Desired Dose X Quantity = Amount to Administer

Stock on Hand

D x Q = Amount
H
Problem 1:

Erythromycin 500 mg is ordered. It is supplied

in a liquid form containing 250 mg in 5 mL. To
calculate the dosage, the nurse uses the
formula:
Desired Dose X Quantity = Amount to Administer
Stock on Hand

500 mg X 5 mL = 10 mL
250 mg
Problem 2.
MD writes an order for Xanax 2 mg by mouth a
day. Pharmacy dispeneses you with 1 mg per
tablet of Xanax. How many tablets do you
administer per dose?
Answer: 2 tablets/dose
Problem 3:
MD writes an order for Cytotec 0.1 gram by
mouth daily for a patient with peptic ulcer
disease. Pharmacy dispenses you with 100 mg
per tablet. How many tablets do you
administer per dose?
Answer: 1 tablet/dose
THANK YOU!!!
Administering
vaginal
medications
PURPOSE
EQUIPMENT
Vaginal creams, foam, jelly or
suppositories or irrigating
solutions
Applicator
Disposable gloves
Tissues
Paper towel
Perineal pad
Drape
Water soluble lubricant
Bedpans
Irrigation or douche container
MAR or computer printout
STEPS
1. Review physician’s order
including client’s name,
medication name, form (cream,
suppository), route, dosage, and
time of administration.
RATIONALE
Ensures safe and correct client
receives medications.
2.Wash hands
RATIONALE
Reduce transfer of
microorganisms.
3. Identify client; compare name
on MAR with identification
bracelet and asking name
RATIONALE
Ensures that correct client
receives medication
4. Inspect condition of external
genitalia and vaginal canal.
 RATIONALE
Findings provide baseline to
monitor effect of medication
5.Assess client’s ability to
manipulate applicator or suppository
and to position self to insert
medication.
RATIONALE
Mobility restriction indicates level of
assistance required from the nurse.
 6. Explain procedure to client. Be
specific if client plans to self
adminsiter medication.
RATIONALE
Promotes understanding. Will enable
client to self administer medication
if physically able.
7.Arrange supplies at bedside.
RATIONALE
Ensures smooth procedure
8. Close room curtain or door
RATIONALE
 Provides privacy
9. Assist client to lie in dorsal
recumbent position .
RATIONALE
Provides easy access to and good
exposure of vaginal canal. Also
allows suppository to dissolve
without escaping through orifice.
10. Keep abdomen and
extremities draped.
RATIONALE
Minimizes embarrassment
 11. Apply disposable gloves
RATIONALE
Prevents transmission of
microorganisms between nurse
and client.
12. Be sure vaginal orifice is well
illuminated by room light or
gooseneck lamp.
RATIONALE
Proper insertion requires
visualization of external genitalia
13. Insert suppository with gloved
hand:
a. Remove suppository from foil
wrapper and apply liberal amount
of petroleum jelly to smooth or
rounded end. Lubricate gloved
index finger of dominant hand.
RATIONALE
Lubricationreduces friction
against mucosal surfaces during
insertion
b.With non dominant gloved
hand, gently retract labial folds.
RATIONALE
Exposes vaginal orifice
c. Insert rounded end of suppository
along posterior wall of vaginal canal
entire length of finger
RATIONALE
Proper placement ensures equal
distribution od medication along
walls of vaginal cavity.
d.Withdraw finger and wipe
away remaining lubricant from
around orifice and labia.
RATIONALE
Maintains comfort
14. Apply cream or foam
A. Fill cream or foam applicator
following package directions.
RATIONALE
Dose is prescribed by volume in
applicator
B.With non dominant gloved
hand, gently retract labial folds.
RATIONALE
Exposes vaginal orifice
C. With dominant gloved hand
insert applicator approximately
5 to 7.5 cm (2 to 3 inches). Push
applicator plunger to deposit
medication into vagina.
RATIONALE
Allowsequal distribution od
medication along vaginal walls.
D. Withdraw applicator and place
on paper towel. Wipe off residual
cream from labia or vaginal orifice.
RATIONALE
Residual cream on applicator may
contain microorganism.
15. Remove gloves by pulling them
inside out and discard in appropriate
receptacle. Wash hands.
RATIONALE
Reduces transfer of microorganisms
16. Instruct client to remain on back
for at least 10 minutes.
RATIONALE
Medication will be distributed and
absorbed evenly throughout vaginal
cavity and not be lost through the
orifice.
17. If applicator is used, wash with
soap and warm water, rinse and
store for future use.
RATIONALE
Vaginal cavity is not sterile. Soap
and water assist in removal of
bacteria and residual cream.
 18. Offer client perineal pad
when she resumes ambulation.
RATIONALE
Prevents vaginal discharge from
spreading to clothing
19. Inspect appearance of discharge of
vaginal canal and condition of external
genitalia between applications.
RATIONALE
Evaluates whether vaginal medication
effectively reduced irritation or
inflammation of tissues.