chapter 1 the nursing process and drug therapy mosby items and derived items © 2007, 2005, 2002 by...

CHAPTER 1CHAPTER 1

The Nursing Process The Nursing Process and Drug Therapyand Drug Therapy

Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

The Nursing ProcessThe Nursing Process

A research-based organizational framework for A research-based organizational framework for professional nursing practiceprofessional nursing practice

Central to all nursing careCentral to all nursing care Encompasses all steps taken by the nurse in caring Encompasses all steps taken by the nurse in caring

for a patientfor a patient Flexibility is importantFlexibility is important Critical thinkingCritical thinking Ongoing and constantly evolving processOngoing and constantly evolving process


The Nursing Process (cont’d)The Nursing Process (cont’d)

AssessmentAssessment Nursing diagnosisNursing diagnosis Planning Planning

GoalsGoals Outcome criteriaOutcome criteria

ImplementationImplementation EvaluationEvaluation



AssessmentAssessment Data collection Data collection

Subjective, objectiveSubjective, objective Medication historyMedication history

PrescriptionsPrescriptions OTCsOTCs HerbalsHerbals Responses to medications (therapeutic and adverse Responses to medications (therapeutic and adverse

responses)responses)



Nursing diagnosisNursing diagnosis Decision about the need/problem (actual or at Decision about the need/problem (actual or at

risk for) of the patientrisk for) of the patient Critical thinking, creativity, and accurate data Critical thinking, creativity, and accurate data

collectioncollection NANDA formatNANDA format



Nursing diagnosisNursing diagnosis

Three stepsThree steps Human response to illness (actual or risk)Human response to illness (actual or risk) ““related to”related to” ““as evidenced by”as evidenced by”



PlanningPlanning Identification of goals and outcome criteriaIdentification of goals and outcome criteria

Must be specific and measurableMust be specific and measurable Must be patient-centeredMust be patient-centered

Time frameTime frame PrioritizationPrioritization



GoalsGoals Objective, measurable, realisticObjective, measurable, realistic Time frame specifiedTime frame specified

Outcome criteriaOutcome criteria Specific standard(s) of measureSpecific standard(s) of measure Patient orientedPatient oriented



ImplementationImplementation Initiation and completion of the nursing care Initiation and completion of the nursing care

plan as defined by the nursing diagnoses and plan as defined by the nursing diagnoses and outcome criteriaoutcome criteria

Follow the “Five Rights” of medication Follow the “Five Rights” of medication administrationadministration


The Five Rights of The Five Rights of Medication AdministrationMedication Administration

Right drugRight drug Right doseRight dose Right timeRight time Right routeRight route Right patientRight patient


Another “Right”—Constant Another “Right”—Constant System AnalysisSystem Analysis

A “double-check”A “double-check” The entire “system” of medication The entire “system” of medication

administrationadministration Ordering, dispensing, preparing, Ordering, dispensing, preparing,

administering, documentingadministering, documenting Involves the physician, nurse, nursing unit, Involves the physician, nurse, nursing unit,

pharmacy department, and patient educationpharmacy department, and patient education


Other “Rights”Other “Rights”

Proper drug storageProper drug storage Proper documentationProper documentation Accurate dosage calculationAccurate dosage calculation Accurate dosage preparationAccurate dosage preparation Careful checking of transcription of Careful checking of transcription of

ordersorders Patient safetyPatient safety


Other “Rights” (cont’d)Other “Rights” (cont’d)

Close consideration of special situationsClose consideration of special situations Prevention and reporting of medication Prevention and reporting of medication

errorserrors Patient teachingPatient teaching Monitoring for therapeutic effects, Monitoring for therapeutic effects,

adverse effects, toxic effectsadverse effects, toxic effects Refusal of medicationRefusal of medication


Six Elements of a Drug OrderSix Elements of a Drug Order

1. Patient's name1. Patient's name

2. Date order is written2. Date order is written

3. Name of medication3. Name of medication

4. Dosage (includes size, frequency, and number of 4. Dosage (includes size, frequency, and number of doses)doses)

5. Route of delivery5. Route of delivery

6. Signature of the prescriber6. Signature of the prescriber


EvaluationEvaluation

Ongoing part of the nursing processOngoing part of the nursing process Determining the status of the goals and Determining the status of the goals and

outcomes of careoutcomes of care Monitoring the patient’s response to drug Monitoring the patient’s response to drug

therapytherapy Expected and unexpected responsesExpected and unexpected responses


chapter 1 the nursing process and drug therapy mosby items and derived items © 2007, 2005, 2002 by...

Documents