Chapter 1 - The Nursing Process and Drug Therapy Flashcards
What are the 5 Steps of the Nursing Process?
1) Assessment - Data Collection
2) Nursing Diagnosis - Identify a patient need
3) Planning
4) Implementation - Including Patient Education
5) Evaluation
What is the Nursing Process?
- A research-based organizational framework for professional nursing practice
- Ensures the delivery of thorough, individualized, and quality nursing care to patients
- Requires critical thinking
- Ongoing and constantly evolving process
Assessment in Drug Therapy
- What medications/supplements is the patient currently taking
- Swallowing and abilities for meds
- Labs evaluating organs involved in metabolism of the drug.
Common Diagnosis in Drug Therapy
A Human Needs Statement
- Deficient Knowledge
- Risk for Injury
- Noncompliance
- State problem/symptom not specific medical diagnosis.
3 Step Process of Diagnosis
1) Human response to illness, injury, or significant change
2) Factors related to the response
3) Listing of Cues, Clues, Evidence, or other data that supports the nurse’s claim for the diagnosis
What is a Human Needs Statement
Client is experiencing a knowledge deficit related to a new diagnosis of elevated blood pressure as evidenced by the failing to record daily blood pressures in a journal.
Client is non complaint with the new drug regime for elevated blood pressure related to economic issues as evidence by not getting the prescription refilled and a BP of BP of 170/90.
What is planning in Drug Therapy?
- Identification of goals and outcome criteria
Goals in Drug Therapy
Objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria
Outcome Criteria in Drug Therapy
Concrete descriptions of patient goals
Planning Examples
Client will have a BP between 120-130 over 70 to 80
Within one month of treatment.
Client will be proficient in taking a BP reading within 2 weeks of the diagnosis of elevated BP, by demonstration to the nurse.
Implementation in Drug Therapy
Initiation and completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria
Independent, collaborative, and dependent
Client will verbalize daily routine of weighing themselves daily with journal.
Client will verbalize the reason for the medication/ and side effects to report to the Prescriber.
What are the 5 Rights of Medication Administration?
1) Dose
2) Time
3) Route
4) Patient
5) Documentation
Evaluation in Drug Therapy
Ongoing part of the nursing process
Determining the status of the goals and outcomes of care
Monitoring the patient’s response to drug therapy
Expected and unexpected responses
Clear, concise documentation.
Evaluating each intervention, and goals .Making changes as needs for the patient change or goals are not met.
