The Nursing Process
An organizational framework for the practice of nursing. It encompasses all steps taken by the nurse in caring for a patient; assesment, nursing diagnoses, planning (with goals and outcome criteria, implementation of the plan (with patient teaching) and evaluation - p6
Implementation or fulfillment of a prescriber's or care givers prescribed course of treatment or therapeutic plan by a patient - p9
Statements that are time specific and describe generally what is to be accomplished to address a specific nursing diagnosis - p6
Any preventable adverse drug event involving inappropriate medication use by a patient or health care professional; it may or may not cause the patient harm - p 14
An informed decision on the part of the patient not to adhere to or follow a therapeutic plan or suggestion - p9
Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of goals related to each nursing diagnosis. These statements, like goals, should be verifiable, framed in behavioral terms, measureable, and time specific. Outcome criteria are considered to be specific, whereas goals are broad - p6
Any health care professional licensed by the appropriate regulatory board to prescribe medications - p8
List the 5 phases of the nursing process?
1) Assessment - p7
2) Nursing diagnoses - p9
3) Planning (goals and outcome) - p9
4) Implementation (including patient education) - p10
5) Evaluation - p14
The components of the assessment process for patients receiving medications
1) collection of subjective and objective data. methods of collection include; interviewing, direct or indirect questioning, observation, medical records, head-to-toe examination, nursing assessment.
What should A medical profile include?
1) any or all drug use
2) use of home or folk remedies. herbal homeopathic treatments. plant or animal extracts, dietary supplemnts.
3) intake of alcohol, tobacco, and caffeine.
4) current or past history of illegal drug use
5) use of over the counter medications
6) use of hormonal drugs
7) past and present health history and associated drug regimens.
8) family history and racial, ethnic, cultural attributes with attention to specific or special responses
9) growth and developmental stage. isssues related to patients age and medication regimen.
Part 1 of the nursing diagnosis statement
the human response of the patient to illness, injury, or significant change. Can be an actual problem, an increased risk of developong a problem, or an oppoortuinity or intent to improve the patients health.
Part 2 of the nursing diagnosis statement
the factors related to the response, with more than one factor often named. Indicates there is a connection between the factors and the response,
Part 3 of the nursing diagnosis statement
listing of slues, sues, evidence, or other data that supports the nurse's claim that this diagnosis is accurate.
What is the planning step?
prioritize the nursing diagnosis & specify goals and out come criteria, include the time frame, review possible procedure or techniques to be used, gather information for the nure or the patient. planning leads to safe care
what are nursing goals?
objective, measureable, and realisitc with established time period for reaching outcomes,
What is outcome criteria?
concrete descriptions of patients goals. patient focused, succinct, and well thoughtout. include expectations for behavior indicationg something can be change and with a specific deadline. should guide the impementation phase. starts at analysis & ends with nursing care plan. A STANDARD FOR MEASURING MOVEMENT TOWARDS GOALS. address storage, handling techniques of meds, administration procedures, equipment needed, drug interactions, adverse effects, contraindications.
constant communication and collaboration with patient and members of the health care, family. initiation and completion of specific actions by the nurse. maybe independent, collaborative, or dependent upon a prescribers order.
The six rights of medication administration
1) right Drug
2) right Dose
3) right Time
4) right Route
5) Right Patient
6) right documentation
Valid License to practice. check specific medication order against the medication label or profile THREE times. prescribers signiture. generic names should be used to ensuer safe practice.
When should the nurse check the right drug 3 times?
1) while preparing the medication for administration
check dose & confirm appropriate for age and size. check prescribed dose against the available drug sticks and noraml dosage range. check math. leading 0's alound but not following. note patient's variables (vital signs, age, gender, weight, height)
check policy. Given no more than 1/2 before or after time prescriber ordered. must consider multiple-drug therapy, drug-drug, or drug-food compatibility, scheduling of diagnostic stuides, bioavailability of drug, drug actions, biorhythm effects. spell out all terms. no abbreviations.
know the paticulars about each medication before administerig it. a complete medication order does include the route of administration.
check identity. ask to state name. check band for name, identification number, age, allergies.
2008 joint commission national patient safety goals for patient care states;
use of 2 identifiers when providing care, treatment, or services to patients.may be the same location. acceptable indertifiers include name, ( on armbands, writbands) date of birth, social security #. patient identified "reliably" & the service or treatment be matched to individual.
documentation of drug actions, improvment or nonimprovment in patients health, any patient education should be noted. if drug is not given. refusal of medication. actual time of drug administration, data regarding clinical observations and treatment of the patient if a medication error occurred.
What should the patients chart always have?
date and time of medication administration, name of medication, dose, route, and site of administration.
occurs after the nursing plan is implemented. systematic, ongoing, and dynamic phase. monitoring the patients therapeutic response to the drug and its adverse or toxic effects. clear, concise, abbreviation-free charting that records infor related to any aspect of the medication administration process.
2) MONITORING standards of care.