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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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Tags
adverse effect, assessment administration, assessment data, assessment phase, drug storage, drug to drug interactions, family education, health assessment, health evaluation, INTERVENTIONS, nursing diagnosis, nursing management, nursing process, nursing responsibility, physical assessment, placebo effect, process assessment, teaching effectiveness, teaching evaluation, therapy assessment