PART 4: PHARMACOLOGY NURSING PROCESS: PATIENT

Assessment

The phase of the nursing process in which the nurse gathers subjective and objective data about the patient’s health and lifestyle.

Subjective data

The type of data that cannot be directly observed and must be obtained through interviewing the patient.

Dysphagia

The patient’s difficulty swallowing that is considered subjective assessment data.

Subjective data

The patient’s verbalized signs and symptoms of illness.

Current health history

The assessment data that include allergies, financial barriers, use of tobacco, alcohol, caffeine, and herbal remedies.

Objective data

The type of data obtained through physical examination, laboratory results, vital signs, and direct observation.

Physical assessment findings

The assessment finding obtained by seeing, hearing, smelling, and touching the patient.

Diagnosis

The phase of the nursing process in which assessment data are analyzed to determine the patient’s health problems.

Planning

The phase of the nursing process in which patient

Time frame

A characteristic of nursing goals that specifies when the goal should be achieved and reevaluated.

Implementation

The phase of the nursing process in which the nurse provides drug administration, patient education, and nursing interventions.

Evaluation

The phase of the nursing process that determines whether the goals and teaching objectives have been achieved.

Tailored patient teaching

Teaching that is individualized according to the patient’s educational level.

Medical jargon

The communication style that should be avoided during patient teaching because it may reduce patient understanding.

General patient teaching

The principle of patient teaching that includes instructions to take medications as prescribed and notify the health care provider when dose or frequency changes occur.

Side effects teaching

The patient teaching principle that includes explaining expected changes in stool color and precautions for orthostatic hypotension.

Orthostatic hypotension

The side effect that requires teaching the patient to rise slowly from sitting or lying positions.

Self

administration teaching

Diet teaching

The patient teaching principle that includes foods to avoid or include while taking medications.

Cultural considerations

The patient teaching principle that requires sensitivity to the patient’s cultural beliefs and practices.

Right patient

The medication administration right that requires using two forms of patient identification before giving a drug.

The Joint Commission

The organization that requires two forms of patient identification before medication administration.

Right drug

The medication administration right that requires checking the medication at least three times before giving it.

Right dose

The medication administration right that ensures the amount administered is the amount ordered and safe for the patient.

Patient’s weight

The patient factor that is emphasized in determining the correct medication dose.

Right time

The medication administration right that refers to administering the medication at the prescribed time.

Right route

The medication administration right that ensures the medication is given by the correct method for proper absorption.

Ability to swallow

The assessment that should be performed before administering oral medications.

Right assessment

The medication administration right that requires obtaining baseline data before giving the drug.

Right documentation

The medication administration right that requires recording medication information immediately after administration.

Right to education

The medication administration right that requires providing accurate and thorough information about the medication and its relationship to the patient’s condition.

Right evaluation

The medication administration right that determines whether the medication produced the desired therapeutic response.

Right to refuse

The medication administration right that recognizes the patient’s legal ability to decline medication.

Immediate documentation of the refusal

The nursing responsibility that must occur immediately after a patient refuses medication.

Follow

up

Right to a complete and clear order

The nurse’s right to receive an order that is complete and clearly written.

Right to have access to information

The nurse’s right to obtain drug information necessary for safe medication administration.

Right to have policies to guide safe medication administration

The nurse’s right to rely on institutional guidelines that support safe medication administration.

Right to administer medications safely and identify problems in the system

The nurse’s right to identify unsafe conditions and prevent medication errors.

Right to stop, think, and be vigilant

The nurse’s right to pause and critically think before administering any medication.