Chapter 1 Flashcards
Assessment consists of…
objective and subjective data
The nursing process is…
a five step process:
assessment
identification of human needs
planning
implementation of planning
evaluation
Objective data
what is seen, felt, heard, and smelled
Sources of objective data
medical record, lab results, physical assessment, etc.
Subjective data
spoken information that is shared by the patient
Examples of subjective data
complaints, problems, or stated needs
ex. complains of dizziness, headaches, and vomiting
Human Needs Statement
nurse analyzes objective and subjective data to formulate statements of human need fulfillment/alteration
Planning
outcome identification that are patient oriented and provide time frames
- objective, realistic, and measurable
Implementation
nurse intervention to address specific problems and needs
Evaluation
monitoring whether the patient outcomes, related to the human needs statement, are met
Human needs statements are also related to…
drug therapy
A medication history includes…
allergies, any and all drug use, all rx medications, use of home/ herbal treatments, dietary supplements, A/T/C intake, OTC’s, etc.
Patient prescriptions must be checked for the following seven elements…
patient name
date drug order was written
drug name
dosage amount
dosage frequency
route of administration
prescriber signature
Formulation of human need statement
- human need
- address of human need fulfillment or alteration
- evidence supporting claim
9 rights of medication administration
right drug, right dose, right time, right route/form, right patient, and right documentation, right reason/indication, right response, and right to refuse
