Fundamentals session 9:

Today we talked briefly about dosage calculations, then moved on to the main part which covered safety and pain management. In pain management there was a focus on the PCA and self titrating the medication. Happy studying!


Dosing review topics

Pediatric dosing

calculate weight in lbs into kg

  • round to the first decimal place

Calculate the max daily dose by taking the dose amount times the amount of times that it is given

concentration of medication

  • 25,000u/500ml is twice as concentrated as: 25,000u/250ml
  • this means that the drip rate for #2 would be half as fast as #1


risk factors

  • bad systems
  • lack of communication systems
  • lack of standardization
  • fear of punishment for reporting

Culture of safety

  • cannot be a blame culture
  • focus on what went wrong, not the person
  • promote safety through education and training
  • cannot just “try harder” to stop errors
  • periodic assessment of the culture and relationship between the culture, and quality and safety


    • Measures culture of safety
  • reliable valid tools to measure culture of safety

Latent failure (blunt end of care)

  • affect the organizational policies

Active error (sharp end of care)

  • directly contacts the patient

NPSG – (national patient safety goals)

  • yearly update of the foci of the patient safety goals

Work safety

  • Make a “Brain” to make patient notes, to avoid relying on safety
  • work hours and, ratios, and under staffing
  • Using a checklist
  • team training
  • involve patients in care
  • Anticipate problems
  • Recovery – systems set up to improve errors once they occur
  • improving access to accurate information

Human factors

  • relationship between humans and technology
  • always a system contribution to the problem
  • Mindfulness – internal environment

Patients want an honest apology, know exactly what went wrong, and to have the system fixed.

the smetzer article

  • OB setting,
  • nurse thinking ahead but switching the antibiotic medication with the epidural
  • there are many system that added to this error
    • the mom died, but the baby made it.
  • Definitions to remember
    • hindsight bias – remembering differently than it actually happened
    • perceptual blindness – you see what you expect to see, no what is actually there.

Pain management

“Pain is whatever the experiencing person says it is, existing whenever they say it is” – M. McCaffery

Nociceptive pain – damage to somatic or visceral tissue

somatic pain – Localized – superficial or deep, stabbing, aching, throbbing

Visceral pain – damage to nerves PNS or CNS – in terms of internal organs

  • not always fully controlled with opiates

increase in vital signs does not always mean that the patient is in pain

the nurse cannot always tell whether or not the patient is in pain

pain can be associated with depression

there are many different scales but most measure from 0-10, 0 being no pain

  • there needs to be a system about assessment of pain

non medical interventions

  • relaxation
  • meditations
  • hypnosis
  • Acupuncture
  • Therapeutic massage

types of pain medications

opiate, non opiate, and Co-analgesic or adjuvant

fentanyl – is one of the quickest opiates, half life is .5 – 1 hr

respiratory depression is a fear when withholding pain medication

tolerance – need to increase the dose for same effect

physical dependence – suffering when the drug is stopped

IM injection is a bad way to administer pain medication

PCA – patient controlled analgesia

  • can track the number of attempts
  • usually morphine or dilaudid
  • loading dose is already given
    • the medication is locked in the pump
  • the basal rate is the minimum that will be given w/out the button being pushed
  • PCA dose by proxy is controlled by a family member or someone close to the patient
  • the delay/lockout is set so that the dose can only occur a specific amount of times per hour.
  • verify the programming of the pca pump

NARCAN is the antidote for opiates

Epidural analgesia – given into the space around the spine

  • block is a single dose
  • PCEA is a PCA but into the epidural space
  • risk for hypotension
    • fall risk
  • should not be on anticoagulants

maintenance of the epidural catheter

  • reinforce dressing as needed
  • monitor sight for issues

testing sensation for epidural

  • test sensation with ice at levels bilaterally
    • test to area away from numb site
    • OK: T7-L1 L=R
    • OR different: L T7-L1, R: T8- L2

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