Qory Sandioriva - Miss Universe Indonesia 2010

Miss Universe Indonesia 2010, Qory Sandioriva























Profile
Name: Qory Sandioriva
Date of birth: August 17, 1991
Place of birth: Jakarta, Indonesia
Height: 173 cm
Horoscope: Leo
Eye color: brown
Hair color: black
Title: Puteri Indonesia 2009 automatically titled as Miss Universe Indonesia 2010

Make Him Fall in Love ? Mistakes That Will Keep a Man from Falling in Love

Make Him Fall in Love ? Mistakes That Will Keep a Man from Falling in Love

How do you make a man fall in love? How do you keep from pushing him away? What do women need to know to keep a man interested? In order to make a man fall in love, it is just as important to know what not to do as it is to know what you should do. Read on for an explanation.

Men can be quite fickle sometimes. A relationship might seem to be moving along just fine and then it might take only one thing to completely turn a man off. It can be something that is unique only to him, but it is enough to make him lose interest. Here are a few common mistakes you should avoid if you want to keep this from happening to you.

You forget that you matter as an individual. Women will frequently stop living their own lives the minute they find a man. They drop their own interests and often their other acquaintances just to spend all their time with their guy. This will not make a man fall in love. As a matter of fact, it shows a man that you have no life except the one you share with him. This makes you very unappealing and desperate. Keep sight of those things you love to do and the people you love to share time with, and your man will appreciate that he has a woman that has so much happening in her life.

You try way too hard to keep him happy. Is that all you have to do? Should all your time be spent just trying to please your guy? Absolutely not; men don’t like this. They don’t want to be pampered, and they don’t want to become bored with the lack of excitement in their relationship. If you try to do everything for him, he doesn’t feel the allure of having to chase you or fight for you. Show him how you feel in subtle, romantic ways; but, do not spoil him by catering to his every need. He would rather compete for your attention.

You try to force him into love. You cannot, no matter what you do, pressure a man into falling in love with you. Even though you know that you’ve already fallen for him, you just have to be patient and let him realize his love for you without being forced into it. Besides, the more you begin to push, the more he will wonder why you are trying so hard to convince him to fall in love with you. Hang back and give him time and space; he will get there much quicker if you do.

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Process of Falling in Love

Process of Falling in Love

There are two process of falling in love with someone:

Love first sight

Love at first sight is the love that happens suddenly when someone is interested in an object captured by the five senses. It is highly related to physical appearance, such as interest on a pretty face, a sexy body or a very sweet smile. But the love that happens at first sight are not usually last long (lasting), is due to both understand each other yet and personal characteristics of each.

Starting Because Love Used

Such as philosophy or Javanese proverb says "withing tresno jalaran soko kulino", or Love begins because it used to. The process of falling in love like this usually occurs through a rather long process. Where the two know each other, until the Interacting each know the advantages and drawbacks. Then will bear an affection until eventually both fall in love. There are so many advantages to fall in love like this, the relationship will be more mature and lasting as physical appearance is not a major factor of falling in love, but harmony, compatibility and mutual understanding the advantages and disadvantages of each.

Well, that's the process of falling in love, where someone can say you're in love that makes everything so beautiful.

8 Meaning of Love

8 8 Meaning of Love

Talking about love is never ending, whether it be to see, hear or feel it's all so beautiful.

And love itself is universal, has a million meanings, meaning a million or even if written in one book would not be enough though.

But this time I'll write the love from the perspective of a different, here is 8 Meaning of Love :

Meaning of Love "Agriculture":
"Love must be nurtured, so that love can flourish and reap the happiness in the future".

Meaning of Love "Mathematics":
"Love is need a formula, to love so focused and not fall into a problem later".

Meaning of Love "Medicine":
"Love is need antibiotics, so in love so have immunity and makes love with something that is fun is not considered to be a virus".

Meaning of Love the "Bank":
"Love is the necessary investment, so love to have enough capital to give happiness to our partners".

Meaning of Love "Housewife":
"Love it needs a little seasoning, so that love was bland but delicious and feels delicious on both".

Meaning of Love "Sports":
"Love is need to exercise, for the love of fitness and stamina has not weakened if the illness".

Meaning of Love "comedian":
"Love is needed humor and laughter, to love not only tears and pain".

Meaning of Love "Infotaiment":
"Love it needed a bit of gossip, so that later married scrubbed more sip .... Hehehe".

Nursing Diagnosis and Rationales

Nursing diagnoses are not medical diagnoses. They do not identify a disease but rather existing or potential health problems that require intervention. There is a guideline created by the North American Nursing Diagnosis Association (NANDA) that should be followed but can be slightly customized depending on the work-place policy.

Types
There are five types of nursing diagnoses. An actual diagnosis is based on a definable problem, such as pain. A risk diagnosis is made based on the likelihood of a problem occurring and begins with "risk for." A possible diagnosis refers to a problem that is suspected but not confirmed. This alerts other caregivers to watch for signs of an actual problem. A wellness diagnosis is made when a patient shows the desire to take control of her own well-being. An example is Readiness for Enhanced Parenting, meaning the patient has indicated a readiness to learn more about parenting. Last, there is the syndrome diagnosis, which represents a cluster of actual or risk diagnoses such as Rape-Trauma syndrome. (Fundamentals of Nursing, pg 273)

Writing the Diagnosis
Nurses must follow a set guideline for writing the diagnosis. The first part is the problem and states what health concern is being diagnosed. The second part, the etiology, explains the reason it exists and contains the words "related to," or "RT" for short. The third part is the defining characteristic, and begins with "as manifested by," or "AMB." Some diagnoses do not need the third part. A risk or possible diagnosis will not have defining characteristics because they haven't occurred yet or been proven; however, every diagnosis will contain the first two parts. (Fundamentals of Nursing, pg. 273)

Interventions and Rationales
Every diagnosis must have possible interventions, and those interventions must have rationales. If a patient is diagnosed with a noncompliance, the nurse needs to identify ways to overcome this problem, and those ways need to have a sound medical basis. A possible intervention for noncompliance is to include the patient in planning treatment so he feels he has more control over the situation. (Elsevier Health)

Common Errors
Use evidence, not assumptions. Do not assume that a patient recently diagnosed with cancer is suffering from fear. Look for patterns, not single instances. A new mother who has difficulty breast feeding one out of five times is not ineffective at breastfeeding. Five times in a row is a pattern. Avoid judgmental terms. A patient does not have ineffective coping because he's lazy but because he lacks motivation due to a situational crisis. Prioritize your diagnosis and interventions. A learning deficit cannot be corrected if the patient is suffering from acute pain. (Fundamentals of Nursing, pg.279)

Examples
An example of a three-part diagnosis is "acute pain RT knee surgery AMB patient verbalizing pain." A two part diagnosis would read "risk for disuse syndrome RT immobility." A possible intervention for acute pain is to respond to the patient's complaint of pain promptly. The rationale is that this establishes trust between the patient and the nurse and decreases anxiety. (Elsevier)

Healthy School Lunches For Overweight Kids

Things to Consider
Keep in mind that the school's menu is not near as healthy as some may claim and what you pack will be healthier. Don't purchase chips, cookies and white bread to go into your child'slunchbox. Instead, place nuts with colorful, sweet coating in the bag; not too much since they can be considered unhealthy when consumed in large quantities.

Also, keep in mind that a number of the "kid-friendly" lunch items are "designed for kids" by simply adding a lot of sugar. Instead of kid yogurt, send an "adult" version. Replace fruit snackswith whole fruits, and so on.

And drinks! Stay away from juices, sodas, chocolate milk or whole fat milk, and some sports drinks. Water is always great. You can throw some small water bottles in the freezer the night before. By lunchtime,they'll be thawed, icy cold and refreshing. Sports drinks that are better than most are G2 or Power-Aid Zero, though I haven't found the Power-Aid Zero in the smaller containers.

It may seem like you're eliminating the good parts kids like in their lunchbox but you don't have to be. In lieu of cookies, pudding and more, give your child a mini-sized candy bar that can be found in a number of varieties such as Snickers, Butterfingers, Almond Joy, etc.

Here's a few good, healthy lunches that fit the bill perfectly:
No Bread "Sandwich"

2 oz of good quality lean ham, chicken, or turkey breast (from the deli, not packaged

1 string cheese (low fat)
1 whole fruit
1 vegetable item - something your kid likes, try to stay away from dips like ranch dressing
2 Hershey's kisses or "fun size" candy bars
Small bottle of water or Gatorade G2

Yogurt Pack

1 low fat yogurt (see above note on types to choose)
Granola sprinkles for the yogurt (mix a little flax seed in the granola sprinkles... they'll never notice!)
1 Apple (Gala reigns supreme!)
Flavoured rice cake mini's
2 Hershey's Kisses or mini-candy bars

Egg Pack

1 egg (hardboiled, make sure to peel it for them since kids often do not get more than 15 to 20 minutes for lunch break)
Carrots (baby Supremes do just fine)
Fruit (any kind)
Trail mix (small handful)
1 to 2 mini-candy bars
Water (in water bottle)

It is important to be creative and also talk to your child about what they like and what they don't like. There is no sense in sending a healthy, well planned lunch every day of your child will not eat it. One way to empower your child to make the right choices in things they eat is to send them to a weight loss camp where they will learn these skills. Armed with the knowledge they gain here, they'll be prepared for a life full of healthy eating decisions.

Choose Healthy Diets And Stay Healthy

People engage in diets for the purpose of losing weight. What they don't realize are the other benefits that arise upon engaging in healthy diets. The positive effects include higher energy levels, stronger immune systems, as well as looking great.

There are a lot of diets that that are easy to get into. In fact, most of them guarantee rapid weight loss in a matter of weeks. But how do you really determine if a diet is right for your body weight?

The first tip for an effective diet is calorie counting. Depending on your body mass index and proportion to your height and weight, the limit for daily intake of calories should only be 2,000 especially if you have very limited physical activity.

Healthy diets are composed of the right portion of fruits, vegetables and meat portions plus drinking a lot of water. Diets are not meant to deprive the person of the normal food intake, rather focusing on the food that the body needs to function. Diets also improve a person's self-control and discipline. A normal person who's not on a diet will tend to overeat thinking to satisfy his appetite even if he goes overboard. A person on a diet is more conscious of how he looks and what he eats and ends up achieving a balance.

Carbohydrates play an important role in diets because they energize the body and affect a person's blood sugar levels. When a person is on a diet, he should identify bad carbohydrates and the good ones. Foods that are rich in bad carbs include refined sugar and white rice. These are not good for the body because they elevate sugar levels and can lead to weight gain. Good carbs on the other hand are fruits and vegetables and whole-grain foods. Luckily, whole-grain pasta is now available in supermarkets as alternatives to those who are engaged in diets.

Fiber is a good source of energy because they take time to digest and they don't make us feel as hungry. Foods rich in fiber also even out the blood sugar levels and have other benefits to the colon, aiding to the digestive process.

When eating vegetables, go for the green leafy ones because they contain more nutrients. Bright colored veggies like carrots and lettuce are also good for the body. If you must eat salads, it would be healthy to avoid the dressing because these are fattening and contribute to weight gain.
Protein is also essential to the body because of the amino acids. Foods rich in protein include dairy products like milk and cheese. Walnuts, tofu and soya milk are also some of the healthy proteins that should be included in a diet.

Healthy diets with exercise are a must. When the body is active, it can cause us to lose weight more easily because exercise speeds up metabolism and enables us to digest food better. Sweating is also good for the body because it releases the bad toxins which are also harmful to the helth.

Height and weight are routinely measured for most patients during admission to a health care facility

Height and weight are routinely measured for most patients during admission to a health care facility. An accurate record of the patient's height and weight is essential for calculating dosages of drugs, anesthetics, and contrast agents; assessing the patient's nutritional status; and determining the height-weight ratio. Because body weight provides the best overall picture of fluid status, monitoring it daily proves important for patients receiving sodium-retaining or diuretic medications. Rapid weight gain may signal fluid retention; rapid weight loss may indicate diuresis.

Weight can be measured with a standing scale, chair scale, or bed scale; height can be measured with the measuring bar on a standing scale or with a tape measure for a supine patient. (See Types of scales, page 20.)

Equipment

Standing scale (with measuring bar) or chair or bed scale • wheelchair (if needed to transport patient) • tape measure if needed.

Preparation of equipment

Select the appropriate scale—usually, a standing scale for an ambulatory patient or a chair or bed scale for an acutely ill or debilitated patient. Then check to make sure the scale is balanced. Standing scales and, to a lesser extent, bed scales may become unbalanced when transported.

Implementation

Explain the procedure to the patient.

Using a standing scale

Place a paper towel on the scale's platform.

Tell the patient to remove his robe and slippers or shoes. If the scale has wheels, lock them before the patient steps on. Assist the patient onto the scale and remain close to him to prevent falls.

If you're using an upright balance (gravity) scale, slide the lower rider to the groove representing the largest increment below the patient's estimated weight. Grooves represent 50, 100, 150, and 200 lb. Then slide the small upper rider until the beam balances. Add the upper and lower rider figures to determine the weight. (The upper rider is calibrated to eighths of a pound.)

If using a multiple-weight scale, move the appropriate ratio weights onto the weight holder to balance the scale; ratio weights are labeled 50, 100, and 200 lb. Add ratio weights until the next weight causes the main beam to fall. Then adjust the main beam poise until the scale balances. To obtain the weight, add the sum of the ratio weights to the figure on the main beam.

Return ratio weights to their rack and the weight holder to its proper place.

If you're using a digital scale, make sure the display reads 0 before use. Read the display with the patient standing as still as possible.

If you're measuring height, tell the patient to stand erect on the platform of the scale. Raise the measuring bar beyond the top of the patient's head, extend the horizontal arm, and lower the bar until it touches the top of the patient's head. Then read the patient's height.

Help the patient off the scale, and give him his robe and slippers or shoes. Then return the measuring bar to its initial position.

Using a chair scale

Transport the patient to the weighing area or the scale to the patient's bedside.

Lock the scale in place to prevent it from moving accidentally.

If you're using a scale with a swing-away chair arm, unlock the arm. When unlocked, the arm swings back 180 degrees to permit easy access.

Position the scale beside the patient's bed or wheelchair with the chair arm open. Transfer the patient onto the scale, swing the chair arm to the front of the scale, and lock it in place.

Weigh the patient by adding ratio weights and adjusting the main beam poise. Then unlock the swing-away chair arm as before, and transfer the patient back to his bed or wheelchair.

Lock the main beam to avoid damaging the scale during transport. Then unlock the wheels and remove the scale from the patient's room.

Using a multiple-weight bed scale

Provide privacy, and tell the patient that you're going to weigh him on a special bed scale.

Position the scale next to the patient's bed and lock the scale's wheels. Then turn the patient on his side, facing away from the scale.

Release the stretcher frame to the horizontal position, and pump the hand lever until the stretcher is positioned over the mattress. Lower the stretcher onto the mattress, and roll the patient onto the stretcher.

Raise the stretcher 2″ (5 cm) above the mattress. Then add ratio weights and adjust the main beam poise as for the standing and chair scales.

After weighing the patient, lower the stretcher onto the mattress, turn the patient on his side, and remove the stretcher. Be sure to leave the patient in a comfortable position.

Using a digital bed scale

Provide privacy, and tell the patient that you're going to weigh him on a special bed scale. Demonstrate its operation if appropriate.

Place the protective plastic covering over the stretcher, and confirm that the scale is balanced.

Release the stretcher to the horizontal position; then lock it in place. Turn the patient on his side, facing away from the scale.

Roll the base of the scale under the patient's bed. Adjust the lever to widen the base of the scale, providing stability. Then lock the scale's wheels.

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Center the stretcher above the bed, lower it onto the mattress, and roll the patient onto the stretcher. Then position the circular weighing arms of the scale over the patient, and attach them securely to the stretcher bars.

Pump the handle with long, slow strokes to raise the patient a few inches off the bed. Make sure the patient doesn't lean on or touch the headboard, side rails, or other bed equipment, and that nothing is pulling on the scale (such as I.V. or catheter tubing)because these types of pressure will affect the weight measurement.

Depress the operate button, and read the patient's weight on the digital display panel. Then press in the scale's handle to lower the patient.

Detach the circular weighing arms from the stretcher bars, roll the patient off the stretcher and remove it, and position him comfortably in bed.

Release the wheel lock and withdraw the scale. Dispose of the protective plastic covering and return the stretcher to its vertical position.

Special considerations

Reassure and steady patients who are at risk for losing their balance on a scale.

Weigh the patient at the same time each day (usually before breakfast), in similar clothing, and using the same scale. If the patient uses crutches, weigh him with the crutches. Then weigh the crutches and any heavy clothing and subtract their weight from the total to determine the patient's weight.

Before using a bed scale, cover its stretcher with a drawsheet. Balance the scale with the drawsheet in place to ensure accurate weighing.

When rolling the patient onto the stretcher, be careful not to dislodge I.V. lines, indwelling catheters, and other supportive equipment.

Bed and dialysis scales, with platforms that are placed under the castors of the bed, are useful if frequent weights are needed or the patient is too critically ill to move.

Documentation

Record the patient's height and weight on the nursing assessment form and other medical records, as required by your facility.

Identifying Respiratory Patterns

The chart below shows several common types of respiratory patterns and their possible causes. It's important to assess the patient for the underlying cause and the effect on the patient.
TYPECHARACTERISTICSPATTERNPOSSIBLE CAUSES

ApneaPeriodic absence of breathing
  • Mechanical airway obstruction
  • Conditions affecting the brain's respiratory center in the lateral medulla oblongata
ApneusticProlonged, gasping inspiration followed by extremely short, inefficient expiration
  • Lesions of the respiratory center
BradypneaSlow, regular respirations of equal depth
  • Normal pattern during sleep
  • Conditions affecting the respiratory center: tumors, metabolic disorders, respiratory decompensation, and use of opiates or alcohol
Cheyne-StokesFast, deep respirations of 30 to 170 seconds punctuated by periods of apnea lasting 20 to 60 seconds
  • Increased intracranial pressure, severe congestive heart failure, renal failure, meningitis, drug overdose, and cerebral anoxia
EupneaNormal rate and rhythm
  • Normal respiration
Kussmaul'sFast (over 20 breaths/minute), deep (resembling sighs), labored respirations without pause
  • Renal failure and metabolic acidosis, particularly diabetic ketoacidosis
TachypneaRapid respirations. Rate rises with body temperature: about four breaths per minute for every degree Fahrenheit above normal
  • Pneumonia, compensatory respiratory alkalosis, respiratory insufficiency, lesions of the respiratory center, and salicylate poisoning

Assessment Techniques

To perform physical assessment, a nurse uses four basic techniques: inspection, palpation, percussion, and auscultation. Performing these techniques correctly helps elicit valuable information about the patient's condition.

Inspection requires the use of vision, hearing, touch, and smell. Special lighting and various equipment—such as an otoscope, a tongue blade, or an ophthalmoscope—may be used to enhance vision or examine an otherwise hidden area. Inspection begins during the first patient contact and continues throughout the assessment.

Palpation usually follows inspection, except when examining the abdomen or assessing infants and children. Palpation involves touching the body to determine the size, shape, and position of structures; to detect and evaluate temperature, pulsations, and other movement; and to elicit tenderness.

The four palpation techniques include light palpation, deep palpation, light ballottement, and deep ballottement. Ballottement is the technique used to evaluate a flowing or movable structure. The nurse gently bounces the structure being assessed by applying pressure against it and then waits to feel it rebound. This technique may be used, for example, to check the position of an organ or a fetus.

Percussion uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds, detect tenderness, or assess reflexes. Percussing for sound helps locate organ borders, identify organ shape and position, and determine whether an organ is solid or filled with fluid or gas.

Organs and tissues produce sounds of varying loudness, pitch, and duration, depending on their density. For example, air-filled cavities, such as the lungs, produce markedly different sounds from those produced by the liver and other dense organs and tissues. Percussion techniques include indirect percussion, direct percussion, and blunt percussion.

Auscultation involves listening to various sounds of the body—particularly those produced by the heart, lungs, vessels, stomach, and intestines. Most auscultated sounds result from the movement of air or fluid through these structures.

Usually, the nurse auscultates after performing the other assessment techniques. When examining the abdomen, however, auscultation should occur after inspection but before percussion and palpation. This way, bowel sounds can be heard before palpation disrupts them. Auscultation is best performed first on infants and young children, who may start to cry when palpated or percussed. Auscultation is most successful when performed in a quiet environment with a properly fitted stethoscope.

Equipment

Flashlight or gooseneck lamp, as appropriate • ophthalmoscope • otoscope • stethoscope.

Implementation

Explain the procedure to the patient, have him undress, and drape him appropriately.

Make sure the room is warm and adequately lit to make the patient comfortable and aid visual inspection.

Warm your hands and the stethoscope.


Inspection

Focus on areas related to the patient's chief complaint. Use your eyes, ears, and sense of smell to observe the patient.

To inspect a specific body area, first make sure the area is sufficiently exposed and adequately lit. Then survey the entire area, noting key landmarks and checking its overall condition. Next, focus on specifics—color, shape, texture, size, and movement. Note any unusual findings as well as predictable ones.

Palpation

Explain the procedure to the patient, and tell him what to expect such as occasional discomfort as pressure is applied. Encourage him to relax because muscle tension or guarding can interfere with performance and results of palpation.

Use the flattened fingerpads for palpating tender tissues, feeling for crepitus (crackling) at the joints, and lightly probing the abdomen. Use the thumb and index finger for assessing hair texture, grasping tissues, and feeling for lymph node enlargement. Use the back, or dorsal, surface of the hand when feeling for warmth.

Provide just enough pressure to assess the tissue beneath one or both hands. Then release pressure and gently move to the next area, systematically covering the entire surface to be assessed. (See Performing palpation.)

To perform light palpation, depress the skin, indenting ½Prime; to ¾Prime; (1 to 2 cm). Use the lightest touch possible because excessive pressure blunts your sensitivity.

If the patient tolerates light palpation and you need to assess deeper structures, palpate deeply by increasing your fingertip pressure, indenting the skin about 1½Prime; (4 cm). Place your other hand on top of the palpating hand to control and guide your movements.

To perform light ballottement, apply light, rapid pressure from quadrant to quadrant on the patient's abdomen. Keep your hand on the skin to detect tissue rebound.

To perform deeper ballottement, apply abrupt, deep pressure and then release it. Maintain fingertip contact.

Use both hands (bimanual palpation) to trap a deep, underlying, hard-to-palpate organ (such as the kidney or spleen) or to fix or stabilize an organ (such as the uterus) with one hand while you palpate it with the other.

Percussion

First, decide which of the percussion techniques best suits your assessment needs. Indirect percussion helps reveal the size and density of underlying thoracic and abdominal organs and tissues. Direct percussion helps assess an adult's sinuses for tenderness and elicits sounds in a child's thorax. Blunt percussion aims to elicit tenderness over organs, such as the kidneys, gallbladder, or liver. When percussing, note the characteristic sounds produced. (See Identifying percussion sounds.)

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To perform indirect percussion, place one hand on the patient and tap the middle finger with the middle finger of the other hand. (See Performing indirect percussion.)

To perform direct percussion, tap your hand or fingertip directly against the body surface.

To perform blunt percussion, strike the ulnar surface of your fist against the body surface. Or place the palm of one hand against the body, make a fist with the other hand, and strike the back of the first hand.

Auscultation

First, determine whether to use the bell or diaphragm of your stethoscope. Use the diaphragm to detect high-pitched sounds, such as breath and bowel sounds. Use the bell to detect lower-pitched sounds, such as heart and vascular sounds.

Place the diaphragm or bell of the stethoscope over the appropriate area of the patient's body. Place the earpieces in your ears, listen intently to individual sounds, and try to identify their characteristics. Determine the intensity, pitch, and duration of each sound, and check the frequency of recurring sounds.

Special considerations

Avoid palpating or percussing an area of the body known to be tender at the start of your examination. Instead, work around the area; then gently palpate or percuss it at the end of the examination. This progression minimizes the patient's discomfort and apprehension.

To assess the abdomen, inspect visually first. Then auscultate bowel sounds prior to palpation and percussion, which alter these sounds.

To pinpoint an inflamed area deep within the patient's body, perform a variation on deep palpation: Press firmly with one hand over the area you suspect is involved, and then lift your hand away quickly. If the patient reports that pain increases when you release the pressure, then you've identified rebound tenderness.

NURSING ALERT Suspect peritonitis if you elicit rebound tenderness when examining the abdomen.

If you can't palpate because the patient fears pain, try distracting him with conversation. Then perform auscultation and gently press your stethoscope into the affected area to try to elicit tenderness.

Complications

Palpation may cause an enlarged spleen or infected appendix to rupture.

Documentation

Document your assessment findings and the technique used to elicit those findings—for example, “right lower quadrant tenderness on deep palpation, no rebound tenderness.

Physical Assessment

PHYSICAL ASSESSMENT

Nurses perform a complete physical assessment when the patient is admitted to the facility and partial reassessments as the patient's condition warrants. A complete assessment includes a thorough health history and physical examination. The health history includes the chief complaint, a history of the current illness, general medical and surgical histories, a family history, a social history, and a review of systems.

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Typically, the physical examination follows a methodical, head-to-toe format. Patient preparation includes providing a clear explanation of the examination as well as proper positioning and draping before and during the examination. During this procedure, the nurse must make every effort to recognize and respect the patient's feelings (particularly embarrassment and anxiety) as well as to provide comfort measures and follow appropriate safety precautions.

Equipment

Although equipment varies with the examination's focus, the following may be included: scale with height measurement bar • urine specimen container and laboratory request form (if ordered) • sphygmomanometer • watch with second hand • stethoscope • thermometer • gown (for patient) • examining table (with stirrups if necessary) • gloves • drapes (sheet, bath blanket, or towel, as needed) • adhesive tape • spotlight or gooseneck lamp • flashlight • laryngeal mirror • tongue blades • percussion (reflex) hammer • otoscope • tuning fork • tape measure • visual acuity chart • ophthalmoscope • test tubes of hot and cold water • containers of odorous materials (such as coffee or chocolate) • substances for taste assessment (sugar, salt, vinegar) • coin • pin and cotton • paper clip • fecal occult blood test kit • linen-saver pad • water-soluble lubricant • facial tissues • cotton-tipped applicators • nursing assessment form.

Preparation of equipment

Adjust the temperature in the examining room, and close the doors to prevent drafts. Cover the examining table with a clean sheet or disposable paper. Then assemble the appropriate equipment for the examination.

Implementation

Review the patient's health history to obtain subjective data about the patient and insight into problem areas and subtle physical changes. Investigate the patient's chief complaint. (See Exploring a patient's symptoms.)

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Obtain biographical data, including the patient's name, address, telephone number, contact person, gender, age and birth date, birthplace, Social Security number, marital status, education, religion, occupation, race, nationality, and cultural background as well as the names of persons living with the patient.

Ask about health and illness patterns, the chief complaint, current and past health status, family health status, and condition of body systems.

Ask about health promotion and protection patterns, including health beliefs, personal habits, sleep and wake cycles, exercise, recreation, nutrition, stress level and coping skills, socioeconomic status, environmental health conditions, and occupational health hazards.

Explore the patient's role and relationship patterns, including self-concept, cultural and religious influences, family roles and relationships, sexuality and reproductive patterns, social support systems, and any other psychosocial considerations.

Explain the physical examination and answer questions.

Instruct the patient to void if possible. Collect a urine specimen if ordered. Emptying the bladder increases patient comfort during the examination.

Help the patient undress, and provide a gown. Then measure and record height, weight, and vital signs.

Assist the patient onto the examination table. Requirements for positioning and draping vary with the body system and region being assessed. To examine the head, neck, and anterior and posterior thorax, have the patient sit on the edge of the examination table or the bed. For the abdomen and cardiovascular system, place the patient in a supine position and stand to his right. For a female patient, place a towel over her breasts and upper thorax during abdominal assessment. Pull the sheet down as far as her symphysis pubis, but no farther.

Perform a physical examination. (See Performing a head-to-toe assessment.)


Documentation

Document significant normal and abnormal findings in an organized manner according to the related body systems.

Skin Medications

Topical drugs are applied directly to the skin surface. They include lotions, pastes, ointments, creams, powders, shampoos, patches, and aerosol sprays. Topical medications are absorbed through the epidermal layer into the dermis. The extent of absorption depends on the vascularity of the region.

Nitroglycerin, fentanyl, nicotine, and certain supplemental hormone replacements are used for systemic effects. Most other topical medications are used for local effects. Ointments have a fatty base, which is an ideal vehicle for drugs such as antimicrobials and antiseptics. Typically, topical medications should be applied two or three times per day to achieve their therapeutic effect.


Equipment

Patient's medication record and chart • prescribed medication • gloves • sterile tongue blades • 4″ × 4″ sterile gauze pads • transparent semipermeable dressing • adhesive tape • solvent (such as cottonseed oil).


Implementation

Verify the order on the patient's medication record by checking it against the physician's order on the chart.

Make sure the label on the medication agrees with the medication order. Read the label again before you open the container and as you remove the medication from the container. Check the expiration date.

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.

If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Provide privacy.

Explain the procedure thoroughly to the patient because he may have to apply the medication by himself after discharge.

Wash your hands to prevent cross-contamination, and glove your dominant hand. Use gloves on both hands if exposure to body fluids is likely.

Help the patient assume a comfortable position that provides access to the area to be treated.

Expose the area to be treated. Make sure the skin or mucous membrane is intact (unless the medication has been ordered to treat a skin lesion, such as an ulcer).Applying medication to broken or abraded skin may cause unwanted systemic absorption and result in further irritation.

If necessary, clean the skin of debris, including crusts, epidermal scales, and old medication. You may have to change the glove if it becomes soiled.


Applying paste, cream, or ointment

Open the container. Place the lid or cap upside down to prevent contamination of the inside surface.

Remove a tongue blade from its sterile wrapper, and cover one end with medication from the tube or jar. Then transfer the medication from the tongue blade to your gloved hand.

Apply the medication to the affected area with long, smooth strokes that follow the direction of hair growth. This technique avoids forcing medication into hair follicles, which can cause irritation and lead to folliculitis. Avoid excessive pressure when applying the medication because it could abrade the skin.

To prevent contamination of the medication, use a new tongue blade each time you remove medication from the container.


Removing ointment

Wash your hands and apply gloves. Then rub solvent on them and apply it liberally to the ointment-treated area in the direction of hair growth. Alternatively, saturate a sterile gauze pad with the solvent and use the pad to gently remove the ointment. Remove excess oil by gently wiping the area with a sterile gauze pad. Don't rub too hard to remove the medication because you could irritate the skin.


Applying other topical medications

To apply shampoos, follow package directions. (See Using medicated shampoos.)

To apply aerosol sprays, shake the container, if indicated, to completely mix the medication. Hold the container 6″ to 12″ (15 to 30 cm) from the skin, or follow the manufacturer's recommendation. Spray a thin film of the medication evenly over the treatment area.

To apply powders, dry the skin surface, making sure to spread skin folds where moisture collects. Then apply a thin layer of powder over the treatment area.

To protect applied medications and prevent them from soiling the patient's clothes, tape an appropriate amount of sterile gauze pad or a transparent semipermeable dressing over the treated area. With certain medications (such as topical steroids), semipermeable dressings may be contraindicated. Check medication information and cautions. If you're applying a topical medication to the patient's hands or feet, cover the site with white cotton gloves for the hands or terry cloth scuffs for the feet.

PEDIATRIC ALERT In children, topical medications (such as steroids) should be covered only loosely with a diaper. Don't use plastic pants.

Assess the patient's skin for signs of irritation, allergic reaction, or breakdown.


Special considerations

Never apply medication without first removing previous applications to prevent skin irritation from an accumulation of medication.

Be sure to wear gloves to prevent absorption by your own skin. If the patient has an infectious skin condition, use sterile gloves and dispose of old dressings according to your facility's policy.

Don't apply ointments to mucous membranes as liberally as you would to skinbecause mucous membranes are usually moist and absorb ointment more quickly than skin does. Also, don't apply too much ointment to any skin area because it might cause irritation and discomfort, stain clothing and bedding, and make removal difficult.

Never apply ointment to the eyelids or ear canal unless ordered. The ointment might congeal and occlude the tear duct or ear canal.

Inspect the treated area frequently for adverse effects, such as signs of an allergic reaction.


Complications

Skin irritation, a rash, or an allergic reaction may occur.


Documentation

Record the medication applied; time, date, and site of application; and condition of the patient's skin at the time of application. Note the patient's tolerance and subsequent effects of the medication, if any.


Eye Medications

Eye medications—drops, ointments, and disks—serve diagnostic and therapeutic purposes. During an eye examination, eyedrops can be used to anesthetize the eye, dilate the pupil to facilitate examination, and stain the cornea to identify corneal abrasions, scars, and other anomalies. Eye medications can also be used to lubricate the eye, treat certain eye conditions (such as glaucoma and infections), protect the vision of neonates, and lubricate the eye socket for insertion of a prosthetic eye.

Understanding the ocular effects of medications is important because certain drugs may cause eye disorders or have serious ocular effects. For example, anticholinergics, which are commonly used during eye examinations, can precipitate acute glaucoma in patients with a predisposition to the disorder.


Equipment

Prescribed eye medication • patient's medication record and chart • gloves • warm water or normal saline solution • sterile gauze pads • facial tissues • optional: ocular dressing.


Preparation of equipment

Make sure the medication is labeled for ophthalmic use. Then check the expiration date. Remember to date the container the first time you use the medication. After it's opened, an eye medication may be used for a maximum of 2 weeks to avoid contamination.

Inspect ocular solutions for cloudiness, discoloration, and precipitation, but remember that some eye medications are suspensions and normally appear cloudy. Don't use any solution that appears abnormal. If the tip of an eye ointment tube has crusted, turn the tip on a sterile gauze pad to remove the crust.


Implementation

Verify the order on the patient's medication record by checking it against the physician's order on his chart.

Wash your hands.

Check the medication label against the patient's medication record.

NURSING ALERT Make sure you know which eye to treat because different medications or doses may be ordered for each eye.

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.

If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Explain the procedure to the patient and provide privacy. Put on gloves.

If the patient is wearing an eye dressing, remove it by gently pulling it down and away from his forehead. Take care not to contaminate your hands.

Remove any discharge by cleaning around the eye with sterile gauze pads moistened with warm water or normal saline solution. With the patient's eye closed, clean from the inner to the outer canthus, using a fresh sterile gauze pad for each stroke.

To remove crusted secretions around the eye, moisten a gauze pad with warm water or normal saline solution. Ask the patient to close the eye, and then place the gauze pad over it for 1 or 2 minutes. Remove the pad, and then reapply moist sterile gauze pads, as necessary, until the secretions are soft enough to be removed without traumatizing the mucosa.

Have the patient sit or lie in the supine position. Instruct him to tilt his head back and toward the side of the affected eye so that excess medication can flow away from the tear duct, minimizing systemic absorption through the nasal mucosa.


Instilling eyedrops

Remove the dropper cap from the medication container, if necessary, and draw the medication into it. Be careful to avoid contaminating the dropper tip or bottle top.

Before instilling the eyedrops, instruct the patient to look up and away. This moves the cornea away from the lower lid and minimizes the risk of touching the cornea with the dropper if the patient blinks.

You can steady the hand holding the dropper by resting it against the patient's forehead. Then, with your other hand, gently pull down the lower lid of the affected eye and instill the drops in the conjunctival sac. Try to avoid placing the drops directly on the eyeball to prevent the patient from experiencing discomfort. (See Instilling eye medications.) If you're instilling more than one drop agent, you should wait 5 or more minutes between agents.


Applying eye ointment

Squeeze a small ribbon of medication on the edge of the conjunctival sac from the inner to the outer canthus. Cut off the ribbon by turning the tube. You can steady the hand holding the medication tube by bracing it against the patient's forehead or cheek. If you're applying more than one ribbon of medication, wait 10 minutes before applying the second medication.


Using a medication disk

A medication disk can release medication in the eye for up to 1 week before needing to be replaced. Pilocarpine, for example, can be administered this way to treat glaucoma. (See How to insert and remove an eye medication disk.)


After instilling eyedrops or eye ointment

Instruct the patient to close his eyes gently, without squeezing the lids shut. If you instilled drops, tell the patient to blink. If you applied ointment, tell him to roll his eyes behind closed lids to help distribute the medication over the surface of the eyeball.

Use a clean tissue to remove any excess solution or ointment leaking from the eye. Remember to use a fresh tissue for each eye to prevent cross-contamination.

Apply a new eye dressing if necessary. (See “Hot and cold eye compresses,” page 693.)

Return the medication to the storage area. Make sure you store it according to the label's instructions.

Wash your hands.


Special considerations

When administering an eye medication that may be absorbed systemically (such as atropine), gently press your thumb on the inner canthus for 1 to 2 minutes after instilling drops while the patient closes his eyes. This helps prevent medication from flowing into the tear duct.

To maintain the drug container's sterility, never touch the tip of the bottle or dropper to the patient's eyeball, lids, or lashes. Discard any solution remaining in the dropper before returning the dropper to the bottle. If the dropper or bottle tip has become contaminated, discard it and obtain another sterile dropper. To prevent cross-contamination, never use a container of eye medication for more than one patient.

Teach the patient to instill eye medications so that he can continue treatment at home, if necessary. Review the procedure and ask for a return demonstration.

If an ointment and drops have been ordered, the drops should be instilled first.


Complications

Instillation of some eye medications may cause transient burning, itching, and redness. Rarely, systemic effects may also occur.


Documentation

Record the medication instilled or applied, eye or eyes treated, and date, time, and dose. Note any adverse effects and the patient's response.

How to Insert and Remove an Eye Medication Disk

Small and flexible, an oval eye medication disk consists of three layers: two soft outer layers and a middle layer that contains the medication. Floating between the eyelids and the sclera, the disk stays in the eye while the patient sleeps and even during swimming and athletic activities. The disk frees the patient from having to remember to instill his eyedrops. When the disk is in place, ocular fluid moistens it, releasing the medication. Eye moisture or contact lenses don't adversely affect the disk. The disk can release medication for up to 1 week before needing replacement. Pilocarpine, for example, can be administered this way to treat glaucoma.

Contraindications include conjunctivitis, keratitis, retinal detachment, and any condition in which constriction of the pupil should be avoided.



To insert an eye medication disk

Arrange to insert the disk before the patient goes to bed. This minimizes the blurring that usually occurs immediately after disk insertion.

Wash your hands and put on gloves.

Press your fingertip against the oval disk so that it lies lengthwise across your fingertip. It should stick to your finger. Lift the disk out of its packet.

Gently pull the patient's lower eyelid away from the eye and place the disk in the conjunctival sac. It should lie horizontally, not vertically. The disk will adhere to the eye naturally.


Pull the lower eyelid out, up, and over the disk. Tell the patient to blink several times. If the disk is still visible, pull the lower lid out and over the disk again. Tell the patient that when the disk is in place, he can adjust its position by gently pressing his finger against his closed lid. Caution him against rubbing his eye or moving the disk across the cornea.

If the disk falls out, wash your hands, rinse the disk in cool water, and reinsert it. If the disk appears bent, replace it.

If both of the patient's eyes are being treated with medication disks, replace both disks at the same time so that both eyes receive medication at the same rate.

If the disk repeatedly slips out of position, reinsert it under the upper eyelid. To do this, gently lift and evert the upper eyelid and insert the disk in the conjunctival sac. Then gently pull the lid back into position, and tell the patient to blink several times. Again, the patient may press gently on the closed eyelid to reposition the disk. The more the patient uses the disk, the easier it should be for him to retain it. If he can't retain it, notify the physician.

If the patient will continue therapy with an eye medication disk after discharge, teach him how to insert and remove it himself. To check his mastery of these skills, have him demonstrate insertion and removal for you.

Also, teach the patient about possible adverse reactions. Foreign-body sensation in the eye, mild tearing or redness, increased mucous discharge, eyelid redness, and itchiness can occur with the use of disks. Blurred vision, stinging, swelling, and headaches can occur with pilocarpine, specifically. Mild symptoms are common but should subside within the first 6 weeks of use. Tell the patient to report persistent or severe symptoms to his physician.



To remove an eye medication disk

You can remove an eye medication disk with one or two fingers. To use one finger, put on gloves and evert the lower eyelid to expose the disk. Then use the forefinger of your other hand to slide the disk onto the lid and out of the patient's eye. To use two fingers, evert the lower lid with one hand to expose the disk. Then pinch the disk with the thumb and forefinger of your other hand and remove it from the eye.

If the disk is located in the upper eyelid, apply long circular strokes to the patient's closed eyelid with your finger until you can see the disk in the corner of the patient's eye. When the disk is visible, you can place your finger directly on the disk and move it to the lower sclera. Then remove it as you would a disk located in the lower lid.

Handheld Oropharyngeal Inhalers

Handheld inhalers include the metered dose inhaler (or nebulizer), the turbo-inhaler, and the nasal inhaler. These devices deliver topical medications to the respiratory tract, producing local and systemic effects. The mucosal lining of the respiratory tract absorbs the inhalant almost immediately. Examples of common inhalants are bronchodilators, used to improve airway patency and facilitate mucous drainage; mucolytics, which attain a high local concentration to liquefy tenacious bronchial secretions; and corticosteroids, used to decrease inflammation.

The use of these inhalers may be contraindicated in patients who can't form an airtight seal around the device and in patients who lack the coordination or clear vision necessary to assemble a turbo-inhaler. Specific inhalant drugs may also be contraindicated. For example, bronchodilators are contraindicated if the patient has tachycardia or a history of cardiac arrhythmias associated with tachycardia.


Equipment

Patient's medication record and chart • metered dose inhaler, turbo-inhaler, or nasal inhaler • prescribed medication • normal saline solution (or another appropriate solution) for gargling • optional: emesis basin. (See Types of handheld inhalers)

Implementation

Verify the order on the patient's medication record by checking it against the physician's order.

Wash your hands.

Check the label on the inhaler against the order on the medication record. Verify the expiration date.

Confirm the patient's identity by asking his name and by checking his name, room number, and bed number on his wristband.

If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Explain the procedure to the patient.


Using a metered dose inhaler

Shake the inhaler bottle to mix the medication and aerosol propellant.

Remove the mouthpiece and cap. Note: Some metered dose inhalers have a spacer built into the inhaler. Pull the spacer away from the section holding the medication canister until it clicks into place.

Insert the metal stem on the bottle into the small hole on the flattened portion of the mouthpiece. Then turn the bottle upside down.

Have the patient exhale; then place the mouthpiece in his mouth and close his lips around it.

As you firmly push the bottle down against the mouthpiece, ask the patient to inhale slowly and to continue inhaling until his lungs feel full. This action draws the medication into his lungs. Compress the bottle against the mouthpiece only once.

Remove the mouthpiece from the patient's mouth, and tell him to hold his breath for several seconds to allow the medication to reach the alveoli. Then instruct him to exhale slowly through pursed lips to keep the distal bronchioles open, allowing increased absorption and diffusion of the drug and better gas exchange.

Have the patient gargle with normal saline solution, if desired, to remove medication from the mouth and back of the throat. (The lungs retain only about 10% of the inhalant; most of the remainder is exhaled, but substantial amounts may remain in the oropharynx.)

Rinse the mouthpiece thoroughly with warm water to prevent accumulation of residue.


Using a turbo-inhaler

Hold the mouthpiece in one hand, and with the other hand, slide the sleeve away from the mouthpiece as far as possible.

Unscrew the tip of the mouthpiece by turning it counterclockwise.

Firmly press the colored portion of the medication capsule into the propeller stem of the mouthpiece.

Screw the inhaler together again securely.

Holding the inhaler with the mouthpiece at the bottom, slide the sleeve all the way down and then up again to puncture the capsule and release the medication. Do this only once.

Have the patient exhale and tilt his head back. Tell him to place the mouthpiece in his mouth, close his lips around it, and inhale once—quickly and deeply—through the mouthpiece.

Tell the patient to hold his breath for several seconds to allow the medication to reach the alveoli. (Instruct him not to exhale through the mouthpiece.)

Remove the inhaler from the patient's mouth, and tell him to exhale as much air as possible.

Repeat the procedure until all the medication in the device is inhaled.

Have the patient gargle with normal saline solution, if desired, to remove medication from the mouth and back of the throat. Be sure to provide an emesis basin if the patient needs one.

Discard the empty medication capsule, put the inhaler in its can, and secure the lid. Rinse the inhaler with warm water at least once a week.


Using a nasal inhaler

Have the patient blow his nose to clear his nostrils.

Shake the medication cartridge and then insert it in the adapter. (Before inserting a refill cartridge, remove the protective cap from the stem.)

Remove the protective cap from the adapter tip.

Hold the inhaler with your index finger on top of the cartridge and your thumb under the nasal adapter. The adapter tip should be pointing toward the patient.

Have the patient tilt his head back. Then tell him to place the adapter tip into one nostril while occluding the other nostril with his finger.

Instruct the patient to inhale gently as he presses the adapter and the cartridge together firmly to release a measured dose of medication. Be sure to follow the manufacturer's instructions. With some medications, such as dexamethasone sodium phosphate (Turbinaire), inhaling during administration isn't desirable.

Tell the patient to remove the inhaler from his nostril and to exhale through his mouth.

Shake the inhaler, and have the patient repeat the procedure in the other nostril.

Have the patient gargle with normal saline solution to remove medication from his mouth and throat.

Remove the medication cartridge from the nasal inhaler, and wash the nasal adapter in lukewarm water. Let the adapter dry thoroughly before reinserting the cartridge.


Special considerations

When using a turbo-inhaler or nasal inhaler, make sure the pressurized cartridge isn't punctured or incinerated. Store the medication cartridge below 120° F (48.9° C).

If you're using a turbo-inhaler, keep the medication capsules wrapped until needed to keep them from deteriorating.

Spacer inhalers may be recommended to provide greater therapeutic benefit for children and for patients who have difficulty with coordination. A spacer attachment is an extension to the inhaler's mouthpiece that provides more dead-air space for mixing the medication. Some inhalers have built-in spacers.

Teach the patient how to use the inhaler so that he can continue treatments himself after discharge, if necessary. Explain that overdosage—which is common—can cause the medication to lose its effectiveness. Tell him to record the date and time of each inhalation as well as his response to prevent overdosage and to help the physician determine the drug's effectiveness. Also, note whether the patient uses an unusual amount of medication—for example, more than one cartridge for a metered-dose nebulizer every 3 weeks. Inform the patient of possible adverse reactions.

If more than one inhalation is ordered, advise the patient to wait at least 2 minutes before repeating the procedure.

If the patient is also using a steroid inhaler, instruct him to use the bronchodilator first and then wait 5 minutes before using the steroid. This allows the bronchodilator to open the air passages for maximum effectiveness.


Documentation

Record the inhalant administered as well as the dose and time. Note any significant change in the patient's heart rate and any other adverse reactions.

Eardrops

Eardrops may be instilled to treat infection and inflammation, soften cerumen for later removal, produce local anesthesia, or facilitate removal of an insect trapped in the ear by immobilizing and smothering it.

Instillation of eardrops is usually contraindicated if the patient has a perforated eardrum, but it may be permitted with certain medications and adherence to sterile technique. Other conditions may also prohibit instillation of certain medications into the ear. For instance, instillation of drops containing hydrocortisone is contraindicated if the patient has herpes, another viral infection, or a fungal infection.


Equipment

Prescribed eardrops • patient's medication record and chart • light source • facial tissue or cotton-tipped applicator • optional: cotton ball, bowl of warm water.


Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order.

To avoid adverse effects (such as vertigo, nausea, and pain) resulting from instillation of eardrops that are too cold, warm the medication to body temperature in the bowl of warm water or carry it in your pocket for 30 minutes before administration. If necessary, test the temperature of the medication by placing a drop on your wrist. (If the medication is too hot, it may burn the patient's eardrum.) Before using a glass dropper, make sure it isn't chipped to avoid injuring the ear canal.

Implementation

Wash your hands.

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.

If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

Provide privacy if possible. Explain the procedure to the patient.

Have the patient lie on the side opposite the affected ear.

Straighten the patient's ear canal. For an adult, pull the auricle of the ear up and back. (See Positioning the patient for eardrop instillation.)

PEDIATRIC ALERT For an infant or a child under age 3, gently pull the auricle down and back because the ear canal is straighter at this age.

Using a light source, examine the ear canal for drainage. If you find any, clean the canal with a tissue or cotton-tipped applicator because drainage can reduce the medication's effectiveness.

Compare the label on the eardrops with the order on the patient's medication record. Check the label again while drawing the medication into the dropper. Check the label for the final time before returning the eardrops to the shelf or drawer.

To avoid damaging the ear canal with the dropper, gently support the hand holding the dropper against the patient's head. Straighten the patient's ear canal once again, and instill the ordered number of drops. To avoid patient discomfort, aim the dropper so that the drops fall against the sides of the ear canal, not on the eardrum. Hold the ear canal in position until you see the medication disappear down the canal. Then release the ear.

Instruct the patient to remain on his side for 5 to 10 minutes to let the medication run down into the ear canal.

If ordered, tuck the cotton ball loosely into the opening of the ear canal to prevent the medication from leaking out. Be careful not to insert it too deeply into the canalbecause this would prevent drainage of secretions and increase pressure on the eardrum.

Clean and dry the outer ear.

If ordered, repeat the procedure in the other ear after 5 to 10 minutes.

Assist the patient into a comfortable position.

Wash your hands.


Special considerations

Remember that some conditions make the normally tender ear canal even more sensitive, so be especially gentle when performing this procedure. Wash your hands before and after caring for the patient's ear and between caring for each ear.

To prevent injury to the eardrum, never insert a cotton-tipped applicator into the ear canal past the point where you can see the tip. After applying eardrops to soften the cerumen, irrigate the ear as ordered to facilitate its removal.

If the patient has vertigo, keep the side rails of his bed up and help him during the procedure as needed. Also, move slowly and unhurriedly to avoid exacerbating his vertigo.

Teach the patient to instill the eardrops correctly so that he can continue treatment at home, if necessary. Review the procedure and let the patient try it himself while you observe.

If both an ointment and drop have been ordered, the drops should be administered first.


Documentation

Record the medication used, the ear treated, and the date, time, and number of eardrops instilled. Also document any signs or symptoms that the patient experienced during the procedure, such as drainage, redness, vertigo, nausea, and pain.

Secondary I.V. Lines

A secondary I.V. line is a complete I.V. set—container, tubing, and microdrip or macrodrip system—connected to the lower Y-port (secondary port) of a primary line instead of to the I.V. catheter or needle. It can be used for continuous or intermittent drug infusion. When used continuously, a secondary I.V. line permits drug infusion and titration while the primary line maintains a constant total infusion rate.

When used intermittently, a secondary I.V. line is commonly called a piggyback set. In this case, the primary line maintains venous access between drug doses. Typically, a piggyback set includes a small I.V. container, short tubing, and a macrodrip system. This set connects to the primary line's upper Y-port, also called a piggyback port. Antibiotics are most commonly administered by intermittent (piggyback) infusion. To make this set work, the primary I.V. container must be positioned below the piggyback container. (The manufacturer provides an extension hook for this purpose.)

Most drugs can be piggybacked with a needle-free system, which consists of a blunt-tipped plastic insertion device and a rubber injection port. The port may be part of a special administration set or an adapter for existing administration sets. The rubber injection port has a preestablished slit that can open and reseal immediately. The needle-free system aims to reduce the risk of accidental needle-stick injuries.

I.V. pumps may be used to maintain constant infusion rates, especially with a drug such as lidocaine. A pump allows more accurate titration of drug dosage and helps maintain venous access because the drug is delivered under sufficient pressure to prevent clot formation in the I.V. cannula.

Equipment

Patient's medication record and chart • prescribed I.V. medication • prescribed I.V. solution • administration set with secondary injection port • needleless adapter • alcohol pads • 1″ adhesive tape • time tape • labels • infusion pump • extension hook and appropriate solution for intermittent piggyback infusion • optional: normal saline solution for infusion with incompatible solutions.

For intermittent infusion, the primary line typically has a piggyback port with a backcheck valve that stops the flow from the primary line during drug infusion and returns to the primary flow after infusion. A volume-control set can also be used with an intermittent infusion line.

Preparation of equipment

Verify the order on the patient's medication record by checking it against the physician's order. Wash your hands. Inspect the I.V. container for cracks, leaks, and contamination, and check drug compatibility with the primary solution. Verify the expiration date. Check to see whether the primary line has a secondary injection port. If it doesn't and the medication is to be given regularly, replace the I.V. set with one that has a secondary injection port.

If necessary, add the drug to the secondary I.V. solution. To do so, remove any seals from the secondary container, and wipe the main port with an alcohol pad. Inject the prescribed medication, and gently agitate the solution to mix the medication thoroughly. Properly label the I.V. mixture. Insert the administration set spike and attach the needle. Open the flow clamp and prime the line. Then close the flow clamp.

Some medications are available in vials that are suitable for hanging directly on an I.V. pole. Instead of preparing medication and injecting it into a container, you can inject diluent directly into the medication vial. Then you can spike the vial, prime the tubing, and hang the set, as directed.

Implementation

Confirm the patient's identity by asking his name and checking the name, room number, and bed number on his wristband.

If your facility utilizes a bar code scanning system, be sure to scan your ID badge, the patient's ID bracelet, and the medication's bar code.

If the drug is incompatible with the primary I.V. solution, replace the primary solution with a fluid that's compatible with both solutions, such as normal saline solution, and flush the line before starting the drug infusion. Many facility protocols require that the primary I.V. solution be removed and that a sterile I.V. plug be inserted into the container until it's ready to be rehung. This maintains the sterility of the solution and prevents someone else from inadvertently restarting the incompatible solution before the line is flushed with normal saline solution.

Hang the secondary set's container, and wipe the injection port of the primary line with an alcohol pad.

Insert the needleless adapter from the secondary line into the injection port, and secure it to the primary line.

To run the secondary set's container by itself, lower the primary set's container with an extension hook. To run both containers simultaneously, place them at the same height. (See Assembling a piggyback set, page 250.)

Open the clamp and adjust the drip rate. For continuous infusion, set the secondary solution to the desired drip rate; then adjust the primary solution to achieve the desired total infusion rate.

For intermittent infusion, adjust the primary drip rate, as required, on completion of the secondary solution. If the secondary solution tubing is being reused, close the clamp on the tubing and follow your facility's policy: Either remove the needleless adapter and replace it with a new one, or leave it securely taped in the injection port and label it with the time it was first used. In this case, also leave the empty container in place until you replace it with a new dose of medication at the prescribed time. If the tubing won't be reused, discard it appropriately with the I.V. container.

Special considerations

If policy allows, use a pump for drug infusion. Put a time tape on the secondary container to help prevent an inaccurate administration rate.

When reusing secondary tubing, change it according to your facility's policy, usually every 48 to 72 hours. Similarly, inspect the injection port for leakage with each use, and change it more often if needed.

Unless you're piggybacking lipids, don't piggyback a secondary I.V. line to a total parenteral nutrition line because of the risk of contamination. Check your facility's policy for possible exceptions.


Complications

The patient may experience an adverse reaction to the infused drug. In addition, repeated punctures of the secondary injection port can damage the seal, possibly allowing leakage or contamination.

Documentation

Record the amount and type of drug and the amount of I.V. solution on the intake and output and medication records. Note the date, duration and rate of infusion, and patient's response, where applicable.