UNIT 2 Flashcards
- Well-established, research supported framework for professional nursing practice
-It is accessible, adaptable, and adjustable high-step process consisting assessment, nursing diagnosis, planning, and the esblihment of goal and outcome criteria, implementation
-ensures the delivery of thorough individualized nursing care to patients regardless of age, gender, medical diagnosis, or setting.
nursing process
Major part of nursing process
- involves the use of the mind and thought processes to gather information and develop conclusion
Critical thinking
The elements of nursing process:
-physical
-emotional
-spiritual
-sexual
-financial
-cultural
-cognitive aspects
- data are collected, reviewed, and analyzed
- this allows you to formulate a nursing diagnosis related to the patient needs, specifically to drug administration
Assessment
Information about might come from the variety of sources including the
patient, patient’s family, caregiver, or significant other, and the patient’s chart.
Method of data collection includes:
interviewing, direct and indirect questioning, observation, medical records review, head-to-toe physical examination, and a nursing assessment
Data are categorized into:
objective and subjective data
Any information gathered through the senses; seen, heard, smelled
- may also be obtained by nursing physical assessment, nursing history, past/present medical history, results of laboratory test, diagnostic studies, procedures, measurements of vital signs, weight & height, and medication profile
objective data
data that comes from the patient
subjective data
Medication profiles include but are not limited to the ff information:
-any or all drug use
-use of home/folk/herbal remedies
-homeopathic treatment
-plant or animal extract
-dietary supplements
-intake of alcohol, tobacco, and caffeine
-current or history of illegal drug use
-use of over-the-counter medication such as: aspirin, paracatomol, etc
-family history
-ethnic or cultural attribution which attention to specific to different responses to medications as well as unusual individual responses
-growth and developmental stage
-issues relating to the patient’s age
A holistic nursing assessment includes:
-gathering of data about the whole of individual including the physical, emotional realms, religious preferences, beliefs, socio-cultural characteristics, race/ethnicity, lifestyle, socio-economic status, educational level, motor skills, cognitive level, support system
Include information shared through reliable sources such as: patient, spouse, family member, s/o, caregiver
subjective data
Once assessment of the patient or the drug has been completed, the specific prescription or medication order from the doctor or any prescriber must be check by the following 6 ELEMENTS
- patient’s name
-date of the drug ordered was written
-name of the drug - drug dosage amount and frequency
-route administration
-prescriber’s signature
-Developed by professional nurses as means of communicating and sharing information about the patient and patient’s experience
-result of critical thinking, creativity, accurate collection of data regarding the patient as well as the drug
Nursing diagnosis
Nursing diagnosis related to drug therapy will most likely to grow out of data associated with the ff:
deficient knowledge, risk for injury, non-compliance, and various disturbances, deficits, excess, impairments in bodily function, and or other problems and concerns as related to drug therapy
The development of classification of nursing diagnosis has been carried out by:
North American Nursing Diagnosis Association International (NANDA) (NANDAI)
After the data are collected and the nursing diagnosis are formulated according tot the medication and drug given to the patient
-The main purposes of this is to prioritize the nursing diagnosis, and specify goals and outcome criteria including the time frame for the achievement
Planning
Planning phase includes:
- identification of goals
- outcome criteria
-could be SHORT TERM GOAL or LONG TERM GOAL
Planning should be SMART. What is SMART?
Specific, Measurable, Attainable, Realistic, and Time-bound
Provides time to obtain special equipment for interventions, review the possible procedures or techniques to be used
-leads to provision of safe care if professional judgement is combined with acquisition of knowledge about the patient and medication to be given
Planning/ Planning phase
Are objective, measurable, and realistic, with an established time period for achievement of the outcomes
Goals
-Guided by the proceeding phases of the nursing process
- requires constant communication and collaboration
Implementation
Implementation may be:
Independent, dependent, collaborative
- is common but important clinical procedure
- a manner in which the medicine is administered that will determine to some extent whether or not the patient gains any clinical benefit or whether they suffer
Administration of the medicine/ Drug administration.
Proportion of an administered drug that reaches the systemic circulation and is therefore available for distribution to the intended site of action
Bioavailability of the drug
How the drug is given
Route of administration
Direct entry to the venous system
Intravenous
perfusion blood flow to the muscle and the fat content and temperature of the muscles
Intramuscular
Cold causes ___ or decrease absorption. Heat causes ___ increase in absorption
vasoconstriction ; vasodilation
Perfusion or blood flow to the tissue considering the tissue fat content and temperature of the tissue
Subcutaneous
We have to consider the acidity of the stomach, length of time to the stomach,
Per Orem
perfusion, the blood flow to the rectum, length of time absorption
Per rectal
medicines put underneath the tongue, mucous membrane integrity
Mucous membrane/ sublingual/ buccal
Skin integrity, blood flow to the area
Topical
singhot
Inhalation
Is written by a practitioner for a medication the will be. Here in PH, it comes from the physician
-becomes permanent part
-written, typed, or verbally
Medication Order
-The freedom from accidental injury due to medical care or medical errors during the medication use or process
-to prevent adverse reaction, overdoses, and death
Medication Safety
What are the 7 RIGHTS
- Right Individual
- Right Medication
- Right Dose
- Right time
- Right Route
- Right Documentation
- Right Response
- You have to make sure that you have the right patient
-The standard is to check at least 2 other sources that you have the correct person
Right Individual
Ensuring that you have the right medication
- prevents adverse reaction
-double check, read read read
Right medication
Wrong dose can harm the patient
-the correct dose should be noted in their chart
Right dose
Many medication has specific time that they need to be administered
Right time
Refers to where and how the medication is given to a patient
Right route
It is the sole responsibility or the person administering the medication to properly document
Right documentation
Is the response of a patient to medication
-should be recorded to keep track
Right response
It is a method of determining the correct drug dose for a child based on the known adult dose, assumes that the adult dose is based on a 150 pounds (lb) person
Clark’s rule
Determining a pediatric dose for a child younger than 1 year of age. Based on the child’s age and the usual adult dose. Assume that the adult dose would be appropriate for a 12.5 year old child some naman is 13
Fried’s rule
Determining pediatric drug dose based on the child’s age and the usual adult dose
Young’s rule
T or F
If you have a powdered form, For every 250mg of medication, you need to add 1ml of sterile water
T
Solutions given to a client to have support electrolytes, hydration, for medication and sources of nutrients
IV FLUID
IV fluid comes in two types of bottle:
500ml and 100ml
IV FLUID
Two types of tubing system
macroset and microset
for normal and general application: ____
for pediatric clients, parang may pin sa dulo. and those who are suffering from kidney and heart problems which fluid delivery is very sensitive and closely calculated: ___
macroset ; microset
each tubing system is designed for hospital. use of one tubing system to avoid confusion
Drop factor
Usual drop factor by our local hospitals are
15 drops and 20 drops
Critical part in patient care and patient education about medication administration, therapies or regimes is no exception
Patient education
Is the part of the nursing process that includes monitoring whether the patient goals and outcomes related to the criteria and nursing diagnosis are met
Evaluation
Is crucial to patient’s safety
-recording patient’s observations and nursing actions is an ethical responsibility
Documentation/ recording and reporting
