Nursing Management

Nursing Management

Nursing Responsibility

  • Assessment
  • Administration of ordered medications and therapy
  • Assessment of reaction/outcome to medications
  • Teaching
  • Evaluation of teaching effectiveness

Nursing Process

  • Assessment
    • Gather data: history and physical assessment
  • Nursing diagnosis
    • Draw a conclusion from the assessment data that was gathered
  • Intervention
    • Formulate a plan of care that includes actions to improve or maintain the patient’s health
  • Evaluation
    • Determine if the plan of care was effective at either maintaining or improving the patient’s health

Assessment

  • History
    • Medical
      • Certain conditions prevent patients’ use of some medications
    • Surgical
      • May require new medications as a result of surgery
    • Social
      • Level of education, social support, financial means
  • Medications
    • Drug-to-drug interactions
  • Allergies
    • Patients may have cross-sensitivity to medications

Physical Assessment

  • Head-to-toe assessment
  • Weight
  • Age

Nursing Diagnosis

  • Based on the data collected in the assessment phase of the nursing process
  • The nursing diagnosis is a statement of the patient’s status from the nursing perspective
  • This statement is the basis for the care provided by the nurse
  • Insert box 4.2

Interventions

  • Nursing actions that guide the care provided to the patient by the nurse
  • Interventions can be dependent, interdependent, or independent

Proper Drug Administration (The Rights)

  • Drug
  • Storage
  • Route
  • Dosage
  • Preparation
  • Timing
  • Recording

Promoting Drug Therapy

  • Placebo effect
  • Managing adverse effect
  • Lifestyle adjustment

Patient and Family Education

  • Cornerstone of drug therapy
  • Nurses are the primary educators about medications

Elements of Patient Teaching

  • Name, dose, and action of drug
  • Timing of administration
  • Special storage and preparation instructions
  • Specific OTC drugs or alternative therapies to avoid
  • Special comfort or safety measures
  • Specific points about drug toxicity
  • Specific warnings about drug discontinuation

Patient History

  • Chronic conditions
  • Drug use
  • Allergies
  • Level of education
  • Level of understanding of disease and therapy
  • Social support
  • Financial support
  • Patterns of health care

Physical Assessment

  • Weight
    • Determine whether recommended dose is appropriate
  • Age
    • Extremes often require dosage adjustments
  • Physical parameters related to disease or drug effects
    • Provide a baseline level for future assessments

Medication Order—Hospital

  • Date and time of order
  • Patient name and identifiers (medical record number, date of birth)
  • Drug
  • Dosage
  • Route
  • Frequency
  • Special administration instructions

Medication Order—Community

  • Patient name
  • Patient date of birth
  • Drug
  • Drug dosage
  • Drug route
  • Drug frequency
  • Any special instructions
  • Amount of medication to dispense
  • Number of refills

Drug Administration

  • Assessment of patient
    • Includes history, allergies, physical assessment
  • Assessment of drug
    • Proper medication procedure
  • Teaching
  • Administration of medication
  • Assessing for therapeutic or adverse effect
  • Documentation
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