*Unit 3 - Patient Centered Care Flashcards
Nursing Process
A Delicious PIE
Assess (figure out the weather)
Diagnose (It’s really hot = wear shorts)
Planning (do i need to iron, do laundry, etc.)
Implementing (wear the outfit you decide to wear)
Evaluate (was that a smart idea, how did that work out)
data collection
assessment
first step, and continues through whole nursing process
assessment
- important part of safe and drug therapy
- having all of the necessary information to most effectively treat patient problems and avoid undesired effects
- to obtain baseline information
- being alert to patient responses
assessment
P. 159 - 160, 173-174, 187-189, 203-204
- Obtain compete health history including: cardiovascular, respiratory, musculoskeletal, or thyroid diseases, GI or genitourinary obstruction, or diabetes. Obtain a drug history including allergies, current prescription and OTC drugs, and herbal preparations. Be alert to possible drug interactions
- evaluate appropriate lab findings such as hepatic or renal function studies
- obtain baseline vital signs, bowel sounds, urinary output, muscle strengths, and mental status as appropriate. Assess the patient’s ability to swallow
- Assess the patient’s ability to receive and understand instructions, include patient, family, and caregiver as needed.
Medication Assessment Tool
3 main things of Diagnosis
- Promoting therapeutic drug effects
- *minimizing adverse effects
- maximizing patient self-care (knowledge, skills, resources)
furosemide (lasix = diuretic)…common nursing diagnoses
minimizing adverse effects
- diuretics = pull fluid off the body…too extreme = deficient fluid volume/risk for falls for hypovolemia or hypotension
take insulin: apply diagnoses of self-care deficit or knowledge deficit by not being able to give themselves their medication or not knowing appropriate dosaging
patient teaching to maximize patient self-care
what do we want for the patient
goals/outcomes
what are we going to do about it
interventions
goals/outcomes and interventions fall under what part of the nursing process
planning
minimize factors that contribute to medication errors: avoid using abbreviations that could be misunderstood, question unclear orders, do not accept verbal orders, and follow specific facility policies and procedures related to medication administration. Be aware of situations or settings that may increase the risk of errors, such as a busy environment.
Planning
- administering meds
- patient teaching
- documentation
implementation
3 parts of implementation
- administering meds
- patient teaching
- documentation
actually giving of the meds
implementing
T/F: patient teaching is huge in administrating meds
T
______ get in a habit of documenting as soon as you give your meds and _____ chart meds before you actually give them!
ALWAYS
NEVER
17 things to teach
Caution, Only, Inform, Directions, Follow-up, Report, Double check, pregnant?
- use drugs cautiously
- use only drugs prescribed for you
- inform all health care personnel of all the prescription, OTC, herbs, and dietary supplements that you are taking
- Follow prescribed directions and read the label of OTS medications, herbs and dietary supplements carefully
- Follow up with necessary blood work, office visits or other monitoring directions
- Report allergies, rashes, elevated temp., and difficulty breathing
- Always check with a pharmacist or doctor before taking OTC, herbs, or dietary supplements with prescription drugs
- Always notify the doctor if you are pregnant or breast feeding
Space, Meals, Measure, Store, Discard, Surgery?, Routine, Crush?, Sit!
- space doses around the clock
- follow instructions to take medication with or without food; 1 or 2 hours after meals or before meals
- measure liquid meds
- store meds i na child safe space that is cool and dry
- discard outdated and unused meds
- discontinue herbal products 2-3 weeks before surgery
- develop a routine for taking meds
- do not crush or chew meds unless specifically ordered
- take oral meds in an upright positions with water
Why am I taking this med?
What are the common problems to watch our for?
What should I do if they occur?
When should I stop this med?
Can I take this medicine with the other med on my list?
- If you don’t know the answers to these questions, ask your doctor or pharmacist (or nurse)
- smart consumers ask these questions
NIH
National Institute of Health
- Did the drug Help?
- Were adverse effects kept to a minimum?
- Documentation
Evaluation
3 parts to Evaluation
- Did the drug Help?
- Were adverse effects kept to a minimum?
- Documentation
- benefits should outweigh potential or real harm drug could cause
- med regimens need to be individualized for each patient considering their unique characteristics
- med regimens need to be sensitive to quality of life issues
- dose low and slow
- use the fewest number of meds to get the desired effects
the guiding principles of drug therapy
benefits should _______ potential or real harm drug could cause
outweigh
med regimens need to be _______ for each patient considering their unique characteristics
individualized
med regimens need to be _______ to quality of life issues
sensitive
dose ___ and ____
low and slow
use the _______ of meds to get the desired effects
fewest number
THINK LIKE A NURSE:
You get the following order for your patient:
Morphine 4-10 mg IV q 2 h prn pain
Zofran 2-4 mg IV q 2 h prn nausea
What do you give your patient?
What information about your patient would help you decide?
- depends on the information gathered
- pain level, previous doses time and amount,
ALWAYS chart patient request for pain meds
