chapter 1: The Nursing Process Flashcards
what is the nursing process
A decision-making approach that works to guide health care delivery. Its purpose is to identify, diagnose, and treat human responses to health and illness. Careful attention to each phase of the nursing process promotes positive patient outcomes and promotes adherence to a prescribed drug regimen.
components of nursing process:
Assessment
Diagnosis
Planning
Implementation
Evaluation.
Subjective Data:
Are symptoms described from the patient or family members based on verbal information given.
example of Subjective Data:
Current health history (e.g., difficulty swallowing)
Patient signs and symptoms
Current drugs, including over-the-counter (OTC) drugs, herbal remedies, and nutritional supplements; doses and frequency of drugs
Ability to pay for and access prescribed drugs
Medical and surgical history
Patient’s environment and support system
Objective Data:
Are signs that are directly measured or detected by a health care provider (HCP) regarding the patient’s health.
example:
coughing up yellow mucus
Data from physical health assessment
Laboratory and diagnostic tests
Data from the HCP’s notes
Vital signs
The patient’s body language (facial expression).
Pre-administration assessment:
allows HCPs to establish the baseline data needed to individually tailor drug therapy. By identifying variables that can affect an individual’s responses to drugs, nurses can modify treatment in an attempt to maximize benefit and minimize harm.
Has 4 major goals:
> Establish baseline managements
> Anticipate Adverse Effects
> Identify High- Risk Patients
> Determine Self-Care Capacity
Anticipate Adverse Effects
All drugs can produce side or adverse effects. Usually, the side effects that a drug can produce are known. Baseline measurements can help HCPs determine whether a side or adverse effect has occurred.
Example: Furosemide, a diuretic, can lower a patient’s potassium level. Checking the potassium level before administration of the drug will help the nurse determine whether this side effect has occurred.
Nursing Diagnosis
A nursing diagnosis is made based on analysis of assessment data. Abnormal data serve as the defining characteristics for actual or potential problems.
Common nursing diagnoses related to drug therapy include the following:
Acute pain
Confusion
Decreased adherence
Need for health teaching
Planning
This step involves defining goals, establishing priorities, identifying specific interventions, and establishing criteria for evaluating success. Good planning allows the nurse to promote beneficial pharmacologic outcomes and anticipate side and adverse effects, rather than react to them after the effects occur.
Planning includes:
> Defining goals
> Setting Priorities
> Identifying Interventions
> Establishing Evaluation Criteria
How does a medical diagnosis differ from a nursing diagnosis?
A medical diagnosis identifies a disease process, results of procedures, and results of diagnostic tests.
Nursing diagnoses guide the development of a patient-centered plan of care that promotes safe and effective nursing care
Implementation
Implementation of the drug therapy plan of care has four major components: drug administration, nursing actions to enhance the desired effects of the drug, nursing actions to decrease the side/adverse effect of the drug, and patient education.
Drug Administration
Before the implementation of drug therapy, dosage and route of administration must be considered. The relationship of drug dosing times to mealtimes and administration of concurrent drugs must be taken into consideration
Interventions to Promote Therapeutic Effects
Nonpharmacologic interventions can enhance the desired effects of a drug and should be encouraged (e.g., alternating hot and cold packs for arthritic joint pain
Interventions to Minimize Side/Adverse Effects
Nursing actions that may decrease or prevent side effects and/or adverse effects of a drug are critical components in the plan of care. When planning these actions, the nurse should recognize the difference between a rapid onset drug reaction and a delayed reaction. A severe (and potentially life-threatening) drug reaction, such as anaphylaxis, will occur quickly after administration. If there is any potential for an anaphylactic drug reaction, the nurse must be sure that emergency equipment and personnel are readily available before administration of the drug
Patient Education
Patient education is an ongoing process requiring a dynamic interaction between the nurse and the patient where information is shared.
An outline format for patient education may be helpful because teaching is critical to the success of pharmacologic therapy. Adherence, self-administration, diet, side and adverse effects, and cultural considerations need to be addressed
Five Rights of Drug Administration
Right Patient
Right Drug
Right dose
Right Time
Right Route
Five-Plus-Five Rights of Drug Administration
Right Assessment
Right Documentation
Right Education
Right Evaluation
Right to Refuse
Evaluation
The nurse determines how well goals were met. If goals were not met, nursing interventions and patient education are revised to achieve goal attainment.
components of evaluation:
> Therapeutic Responses
> Adverse Effects
> Adherence
> Patient Satisfaction with Drug therapy
Therapeutic Responses
The patient’s response to drug therapy needs to be evaluated. To adequately and appropriately evaluate the patient’s therapeutic response, it is necessary to know the patient’s baseline data and anticipated patient outcome. It is also important to know the length of time the patient has been taking the drug compared with the expected onset and duration of action for the prescribed drug
Adverse Effects
The nurse must know common adverse effects and evaluate for their presence. In addition, the patient must be evaluated for any unanticipated reaction to drug therapy.
Adherence
Although important for all patients, evaluation of adherence to prescribed drug therapy is especially valuable when the expected therapeutic response is not achieved or when adverse effects are unexpectedly severe. Adherence can be evaluated by interviewing the patient, counting pills to determine whether the anticipated number has been taken, and/or monitoring for therapeutic plasma drug levels. The patient interview can be used to determine patient understanding of drug use, including purpose, timing, dosage, and method of administration
Patient Satisfaction with Drug Therapy
Patient satisfaction with drug therapy is important because it promotes adherence to therapy and increases quality of life. Patient dissatisfaction can lead to nonadherence to pharmacologic therapy. Identification of underlying factors that lead to dissatisfaction is the first step in improving patient adherence; unacceptable side effects, inconvenient dosing schedule, difficulty of administration, and high cost are examples of such factors.
To determine patient response to drug therapy, which factors would the nurse evaluate?
Adherence
Adverse effects
Patient satisfaction
Therapeutic response
Which methods can be used to evaluate the patient’s adherence to a drug regimen?
Interviewing the patient
Counting pills
Measuring plasma drug levels
Which statement describes how the nursing process applies to pharmacology?
It promotes adherence to a prescribed drug regimen.
The nursing process promotes positive patient outcomes and promotes adherence to a prescribed drug regimen.
Which components need to be addressed to facilitate patient adherence to pharmacologic therapy?
Diet
side effects
Self - administration
Cultural considerations
Which interventions related to drug therapy are part of the planning phase of the nursing process?
providing patient education
enhancing therapeutic effects
minimizing drug interactions
Which factors may cause a patient’s dissatisfaction with their current drug regimen?
high cost
unaccepetable side effects
difficulty of administration
inconvenient dosing schedule
