The nursing process beings first with:
an understanding of underlying concepts associated with the art and science of nursing
The nursing process has a flexible, adaptable and adjustable five-step process consisting of:
assessment, nursing diagnoses, planning with outcome identification, with implementation including patient education and evaluation
The five-step nursing process ensures the:
delivery of thorough, individualized and quality nursing care to patients, regardless of age, gender, medical diagnosis or setting
Critical thinking is a major part of the nursing process and involves:
the use of though processes to gather information and then develop conclusions, make decisions, draw inferences and reflect upon all aspects of patient care.
The critical thinking elements address the:
physical, emotional, spiritual, sexual, financial, cultural and cognitive aspects of a patient
include all spoken information shared by the patient, such as complaints, problems or stated needs
include information available through the senses, such as what is seen, felt, heard and smelled. Chart, lab tests, diagnostic procedures, physical assessment and examination findings.
Once the assessment phase has been completed, the nurse analyzes:
objective and subjective data about the patient and the drug and formulates nursing diagnoses; there are 3 parts to assessment
statement of the human response of the patient to illness, injury and medications or significant change.
Deficient knowledge can be:
an actual response, an increased risk or an opportunity to improve the patient's health status
Lack of experience with medication regiment and second-grade reading level as an adult
Identifies factors related to the response, it often includes multiple factors with some degree of connection between them
Evidenced by inability to person a return demonstration and inability to state adverse effects to report to the prescriber
lists clues, cues, evidence and/or data that support the nurse's claim that nursing diagnosis is accurate
The nursing diagnoses are prioritize in order of:
criticality based on patient's needs or problems
The ABC's of care are often used as basis for:
ABC's of care are:
Airway, breathing, circulation
Prioritizing always begins with the:
most important, significant, or critical need of the patient
Nursing diagnoses that involve actual responses are always ranked:
above nursing diagnoses that involve risks.
The planning phase includes:
the identification of outcomes that are patient oriented and provide time frames
The planning outcomes are:
objective, realistic, and measurable patient-centered statements with time frames.
In the implementation phase, the nurse intervenes on behalf of the patient to address:
specific patient problems and needs.
The implementation phase is done through:
independent nursing actions. collaborative activities such as physical therapy, occupational therapy, and music therapy and implementation of medical orders.
monitoring whether patient outcomes, as related to the nursing diagnoses are met
observing for therapeutic effects of drug treatment as well as for adverse effects and toxicity.
If outcomes are met:
the nursing care plan may or may not be revised to include new nursing diagnoses
It outcomes are not met:
revisions are made to the entire nursing care plan with further evaluation
Nine rights of medication administration are:
right drug, right dose, right time, right route & form, right patient, right documentation, right reason, right response, right to refuse
Right drug begins with:
RN's valid license to practice
RN is responsible for:
checking all medication orders and/or prescriptions
Checking all medication orders and/or prescriptions is to ensure:
the correct drug is given
How can you make sure the correct drug is being given?
By checking the medication against the medication label tree times before giving medication
All med orders or prescriptions are required by law to be signed by the:
prescriber involved in the patient's care
If a verbal order is given,
the prescriber must sign the order within 24 hours or as per guidelines within a health care setting
Verbal orders are done in cases of:
emergencies and time-sensitive patient care situations
Avoid relying upon:
the knowledge of peers because this is unsafe nursing practice
What should a nurse know?
the drug's generic name
If there are any questions, who should you contact?
whenever a medication is ordered a dosage is identified from the prescriber's order
Always confirm that:
the dosage amount is appropriate for the patient's age and size
Use of a current, authoritative ______ ___________ is encouraged
Check the prescribed dose against the:
available drug stocks and the normal dosage range
A nurse should pay careful attention to:
Is 0.2mg allowed?
Is 2.0 mg allowed?
Each health care setting or institution has a policy regarding:
routine medication administration times
The medication administration time policies need to be:
checked and committed to memory
Right time should be included in:
your 3 checks
Three checks are:
the frequency of the ordered medication, the time to be administered, and when the last dose of medication was given.
When giving a medication at the prescribe time, you may be confronted with:
a conflict between the timing suggested by the prescriber and specific pharmacokinetic or pharmacodynamics drug properties.
For routine medication orders, the standard of care is to:
give the medications no more than 1/2 hour before of after the actual time specified in prescriber's order
Military time is used when:
medication and other orders are written into a patient's chart
Other factors that must be considered in determining the right time:
multiple-drug therapy, drug-drug, drug-food, scheduling of diagnostic studies, bioavailability of drug, drug actions, biorythym effects
Be careful to write out all words and abbreviations because:
the possibility of miscommunication or misinterpretation poses a risk to the patient
You must know the particulars about each medication before administering it to ensure that:
the right drug, dose, route, and dosage form are being used.
A complete medication order includes:
the route of administration
Checking the patient's identity before giving each medication dose is critical to the:
Confirm the name on the order and the patient, and be sure to use these identifiers:
ask the patient to state his or her names, then check the patient's identification band to confirm the patient's name, identification number, age and allergies
with pediatric patients, the parents and or legal guardians are often the ones who identify the patient for the purpose of administration of prescribed medications
The Joint Commission recommends that the patient be identified:
reliably and also that service or treatment be matched to that individual
Documentation of information related to medication administration is crucial to patient safety and:
recording patient observations and nursing actions has always been an important ethical responsibility
Documentation is now a major:
medical-legal consideration as well
only after the medication has been given
Document any drug action for:
changes in sysmptoms the patient is experiencing, adverse effects, toxicity and any other drug-related physical and or psychological symptoms
Documentation must also reflect any improvement in the patient's condition, symptoms or disease process as well as no change or a lack of improvement and you must:
document these observations and report them to the prescriber promptly
Document any teaching along with:
an assessment of the degree of understanding exhibited by the patient
What should you document?
If any drug is not administered and why and any actions taken.
Actual time of drug administration
Data regarding clinical observations and treatment of the patient if a med error has occurred
If med error has occurred complete:
an incident report
Do not record completion of an I.R. in:
Right reason is:
appropriateness in use of the medication to the patient
Right response is:
the drug and its desired response
Continually assess and evaluate the achievement of the desired response as well as:
any undesired response
Right to refuse:
always respect the patient's right
When a patient has refused a medication, you should:
determine reason, take appropriate action, including notifying prescriber.
Medication errors is a major problem for:
all of health care regardless of the setting
The national coordinating council for medication error reporting and prevention defines a medication error as:
any preventable event that may cause or lead to inappropriate medication use or patient harm while the me is in the control of the health care professional, patient or consumer