2 What is a MAR? It is a legal document It is good for 24 hours It shows all of the medications that a patient is takingDr.’s orders are transcribed on to the MARThe Five rights are all taken into account in filling out the MARRight PatientRight MedRight DoseRight TimeRight Route
3 First thing to fill out on the MAR DatePage number of how manyShift times - For our Testing purposes:Patient Information
4 Adding Medications PO Doctor’s order - Alprazolam 0.5mg PO TID If you have a dose that is NPO after midnight you still put the time down on the MAR the nurse that is going to administer this dose will circle the time on the mar and indicate that the dose was not given. You can clip a note with the instructions that the pt is NPO after midnight if you want.
5 Adding Medications IV Doctor’s Order : Zosyn 3.375mg IVPB Q6H This is incorrect! the Dosage form should be left blank!
6 Adding Medications PRN Doctors Order: Ondansetron HC 4mg PO Q8H PRN for n/vNote: there are no times on a PRN orderPRN orders are always at the bottom of the MAR
7 Adding InsulinDoctor’s Order: Reg Insulin, ac/hs sq, sliding scale BS -100 /10 = unitInsulin always starts at 0730 on our MAR whether ac tid and hs or amOnly regular insulin is on a sliding scaleOnly regular insulin can be administered by IVLook at the dose and ask if it is reasonable < 12 ask the pt if they are resistanta sliding scale may also look like this:under 150 = no insulin= 2 units= 4 units301 – 400 = 6 unitscall the doctor
8 Adding a skin PatchFirst Day – we will only have one day and it needs the date and time we put it onDoctors order: Nitropatch 0.4mg transdermal patch q72h
9 A PO medication that has a stop date Doctor’s order - Alprazolam 0.5mg PO TID X 6 days
10 Times you need to know Medication distribution schedule q day 0900 bidTIDQIDHSinsulin timesQ Every 4 hours from the start timeQ Every 6 hours from the start timeQ Every 8 hours from the start timeQ Every 12 hours from the start time
11 What if something is wrong? Is the Doctor’s order missing something ?look for the 5 rights on the medical orderIs the Rx for the right patient?Do you have the correct medicine?Is it spelled correctly?Is there a correct dose?Is the method correct and listed for the medication?Do you have the correct times listed? are they on the order?Is the patient allergic to this medication? If so STOP write on the back of the MAR that you verified with the patient, checked the armband, and pharmacy for d/cIf you are missing any of these things STOPDo not put it on the front of the MAR instead place it on the back with the reason that it needs clarificationIf you make a mistakeDraw one line through it and write you initials and the word errorMake sure you sign the bottom of the MAR and place your initials in the space provided.
12 Heparin Administration Sub qSites need to be at least one inch apartneeds to be at least two inches from the umbilicusDon’t aspirateDon’t massage the injection siteuse a tuberculin syringeChange the needle between drawing the injection and administering the injectionRotate sites for injectionsinsert the needle degrees depending on the size of the patientuse needle size 23, 25, or 26 gauge ½ or 5/8 inch needle
13 Insulin Administration always check blood sugarneeded suppliesalcohol2X2lancetTest striplet pt pick the fingerwipe with the alcohollet it drymilk it before you poke it (bring blood to the area)one poke; stick on threewipe first drop away with the 2x2second drop on test stripgive gauze to pt to hold on fingercheck parameters with facility to see if you need to retest.do three if you get different numbers on your second test.look at expiration date on the insulin bottlesMake sure the insulin you have iswhat is ordered
14 Insulin Continuedlook at the blood sugar and the MAR and make sure of what our dose is going to belook at big letterpop the topwipe off the top with the alcohol padtake insulin syringedraw all air needed at one timeinject N insulin or cloudy first ALWAYS!!inject air into regular or Clear ALWAYS!!draw Regular first ALWAYS!!check with another licensed personthe needle must still be in the bottlere-wipe off the top of the N insulin(cloudy)Draw the Cloudy second ALWAYS!!Have it checked with another licensed nurseDo not remove the needle till after checkedrecap needle using the one handed technique placing your non dominant hand behind you
15 Insulin Final Check pt. armband Ask about allergies go give to patient subcutaneously at a 45 degree anglewatch pt. know what time to be worried when the regular peaksKnow what time the N is going to peakRegular insulin is the only one that can be given IVAlways use an insulin syringe25, 26, or 27 gauge ½ or 5/8 inchtype Onset Peak DurationRapid acting (Humalog, Novalog) 5-15 min hrs hrsShort acting(Humulin R , Novolin R, Regular) 30min-1hr hr hrsIntermediate acting (NPH, Humulin N) 1-2hrs hrs
16 I.M Injection; Dorsogluteal site Dorsogluteal site - upper outer quadrant of the buttockscan hold 3 mlavoided in clients younger than 3 and non ambulatoryDivide the buttock into four imaginary quadrantsPalpate the posterior iliac spine and the greater trochanterDraw an imaginary diagonal line between the two landmarksInsert the needle superiorly and laterally to the midpoint of the diagonal line.IM Needle sizes 20,21,22,23 1 1/2 or 2 inch 3 or 5 ml
17 Intramuscular : Ventrogluteal Site Uses the gluteus medius and gluteus minimus muscles in the hip for injectionAdvantagesno large nervesno large blood vesselsusually less fattycleaner – no fecal contaminationLocationPlace the palm of the hand on the greater trochanter and the index finger on the anterior superior iliac spineMove the middle finger away from the index finger s far as possible along the iliac crest.Inject into the center of the triangle formed by the index finger, middle finger, and iliac crest.3ml max
18 Intramuscular: Rectus Femoris Site Location: The anterior aspect of the thigh.May be used for infantsclient must be sitting or supineMiddle third of the thigh3mlONLY for PEDS for adults use the vastus laterales
19 Intramuscular: Vastus Lateralis site Uses the vastus lateralis muscle, one of the muscles in the quadriceps group of the outer thigh.desirable site for infant shotsgood for thin or poorly developed clientsLocationplacing one hand above the knee and one hand just below the greater trochanter at the top of the thigh.Insert the needle into the lateral area of the thigh between where your hands were located.3ml
20 Intramuscular: Deltoid Site located in the lateral aspect of the upper arm.least used intramuscular siteSmaller muscle only takes 1mlrisk of damaging the Radial nerveLocationhave the client lie down, sit or stand with the shoulder well exposedPalpate the lower edge of the acromion processdraw and imaginar line at the axillainject in the area between these tow landmarks
21 Common sizes of syringes and needles Intradermal (tuberculin) 1ml calibrated in 0.01 mL or in minims gauge ½ to 5/8 “Subcutaneous 1,2,2.5,3 mL calibrated in 0.1mL 23,25,26, ½ to 5/8Insulin, given subcutaneously 1mL calibrated in units 25,26,27 gauge ½ to 5/8”Intramuscular 3 or 5 mL calibrated in 0.2 mL 20,21,22,23 gauge 1 ½ or 2 inch
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