Tablets, capsules, liquids, suspensions, elixirs, lozenges
● Most common route
● Least expensive ●
Convenient NURSING ACTIONS
● For liquids, suspension, and elixirs, follow directions for dilution and shaking. To prepare the medication, place a medicine cup on a flat surface before pouring, and ensure the base of the meniscus (lowest fluid line) is at the level of the dose. ● Contraindications for oral medication administration include vomiting, decreased GI motility, absence of a gag reflex, difficulty swallowing, and a decreased level of consciousness. ● Have clients sit upright at a 90° angle to facilitate swallowing. ● Administer irritating medications (analgesics) with small amounts of food. ● Do not mix with large amounts of food or beverages in case clients cannot consume the entire quantity. ● Avoid administration with interacting foods or beverages (grapefruit juice). ● Administer oral medications as prescribed, and follow directions for whether medication is to be taken on an empty stomach (30 min to 1 hr before meals, 2 hr after meals) or with food. ● Follow the manufacturer's directions for crushing, cutting, and diluting medications. Break or cut scored tablets only. ● Make sure clients swallow enteric-coated or time-release medications whole. ● Use a liquid form of the medication to facilitate swallowing whenever possible.
Seizure precautions (measures to protect clients from injury during a seizure) are imperative for clients who have a history of seizures that involve the entire body and/or result in unconsciousness.
● Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. Clients at high risk for generalized seizures should have a saline lock in place for immediate IV access.
● Ensure rapid intervention to maintain airway patency.
● Inspect the client's environment for items that could cause injury during a seizure, and remove items that are not necessary for current treatment. ● Assist clients at risk for seizures with ambulation and transferring to reduce the risk of injury.
● Advise all caregivers and family not to put anything in the client's mouth (except an airway for status epilepticus) during a seizure.
● Advise all caregivers and family not to restrain the client during a seizure but to lower the client to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible, and loosen their clothing
- fall-risk assessment for each client at admission and at regular intervals. instruct a client who has orthostatic hypotension to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking.
● Be sure the client knows how to use the call light (by giving a return demonstration), that it is in reach, and to encourage its use.
● Respond to call lights in a timely manner.
● Use fall-risk alerts (color-coded wristbands).
● Provide regular toileting and orientation of clients who have cognitive impairment.
● Provide adequate lighting.
● Orient clients to the setting to make sure they know how to use all assistive devices (grab bars) and can locate necessary items.
● Place clients at risk for falls near the nurses' station.
● Provide hourly rounding.
● Make sure' bedside tables, overbed tables, and frequent-use items (telephone, water, facial tissues) are within reach.
● Keep the bed in the low position and lock the brakes. ● For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up.
● Avoid the use of full side rails for clients who get out of bed or attempt to get out of bed without assistance. ● Provide nonskid footwear and nonskid bath mats for use in tubs and showers.
● Use gait belts and additional safety equipment when moving clients.
● Keep the floor clean, dry, and free from clutter with a clear path to the bathroom (no scatter rugs, cords, or furniture)
Keep assistive devices nearby after validation of safe use (eyeglasses, walkers, transfer devices).
● Educate the client and family about safety risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance.
● Lock the wheels on beds, wheelchairs, and carts to prevent them from rolling during transfers or stops.
● Use electronic safety monitoring devices (chair or bed sensors) for clients at risk for getting up without assistance to alert staff of independent ambulation.
● Report and document all incidents. This provides valuable information that can help prevent similar incidents.
● Stay with the client, and call for help. ● Maintain airway patency and suction PRN. ● Administer medications. ● Note the duration of the seizure and the sequence and type of movements. ● After a seizure, determine mental status and measure oxygenation saturation and vital signs. Explain what happened, and provide comfort, understanding, and a quiet environment for recovery. ● Document the seizure with any precipitating behavior and a description of the event (movements, injuries, duration of seizures, aura, postictal state), and report it to the provider.