Chp 1-2 Nursing Process/Pharmacology Flashcards
What are the 5 steps of the Nursing Process?
- Assessment
- Nursing diagnosis
- Planning (goals, outcome criteria)
- Implementation including patient education
- Evaluation
In the Nursing Process, what happens during the assessment?
Data collection, review, and analysis
Medical profile including drug use; prescriptions; OTC meds; vitamins, herbs, and supplements; compliance and adherence
In the Nursing Process, what is the nursing diagnosis used for?
to communicate and share info about the patient and the patient experience
What are common nursing diagnoses related to drug therapy?
Deficient knowledge
Risk for injury
Noncompliance
What are the three steps in the nursing diagnosis process?
- Human response to illness, injury, or significant change
- Factors related to the response (“related to”)
- Listing of cues, clues, evidence, or other data that support the nurse’s claim for the diagnosis (“as evidenced by”)
In the Nursing Process, what happens during planning?
- Identification of goals and outcome criteria
- Goals (objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria)
- Outcome criteria (concrete descriptions of patient goals)
What does NPO mean?
Nothing by mouth is a medical instruction meaning to withhold food and fluids. It is also known as nil per os (npo or NPO), a Latin phrase whose English translation is most literally, “nothing through the mouth”.
Could you give a patient the same dosage of a drug via IV as you could orally?
No, the dosage for the IV route would not be the same as for the PO (by mouth) route
In the Nursing Process, what happens during implementation?
- Initiation and completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria
- Independent, collaborative, dependent
What are the “Six Rights” of medication administration?
- Right drug
- Right dose
- Right time
- Right route
- Right patient
- Right documentation
In the Nursing Process, what happens during evaluation?
- *Ongoing part of the nursing process
- Determine the status of the goals and outcomes of care
- Monitoring the patient’s response to drug therapy (expected and unexpected responses)
- Clear concise documentation
If an error in the administration of medication is made, what steps should be followed?
The nurse should complete an incident report with the entire event, surrounding circumstances, therapeutic response, adverse effects, and notification of the prescriber described in detail. However, the nurse should not record completion of the report in the medical chart themselves.
Compliance
Implementation or fulfillment of a prescriber’s or caregiver’s prescribed course of treatment or therapeutic plan by a patient.
Medication error
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.
Noncompliance
An informed decision on the part of the patient not to adhere to or follow a therapeutic plan or suggestion.
Nursing process
An organizational framework for the practice of nursing. It encompasses all steps taken by the nurse in caring for a patient: assessment, nursing, diagnoses, planning, implementation of the plan, and evaluation.
Outcomes
Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of behaviors related to each nursing diagnosis. These statements are specific while framed in behavioral terms and are measurable.
Prescriber
Any health care professional licensed by the appropriate regulatory board to prescribe medications.
Objective data
Information available through the senses, such as what is seen, felt, heard, and smelled. (age, height, weight, allergies, medication profile, and health history)
Subjective data
data that includes all spoken information shared by the patient, such as complaints, problems, or stated needs.
QSEN
Quality of Safety Education for Nurses - attempts to address the continued challenge of preparing future nurses with the knowledge, skills, and attitudes needed to continuously improve the quality and safety of patient care within the health care system.
KSA’s
knowledge, skills, and attitudes
EBP
evidence-based practice
QI
Quality improvement
What are the 6 major QSEN initiatives?
- patient-centered care
- teamwork and collaboration
- evidence-based practice
- quality improvement
- safety
- informatics
What seven elements must be checked regarding the medication order?
- patient’s name
- date the drug order was written
- name of drug
- drug dosage amount
- drug dosage frequency
- route of administration
- prescriber’s signature
NANDA-I
North American Nursing Diagnosis Association International
What is the purpose of NANDA-I
to increase the visibility of nursing’s contribution to the care of patients and to further develop, refine, and classify the information and phenomena related to nurses and professional nursing practice.
