NSG 251 The Nursing Process and Drug Therapy

The nursing process

1. Assessment

2. Human needs statement

3. Planning (goals)

4. Implementation (patient teaching)

5. Evaluation

Critical think is a major part of the nursing process

It involves gathering data, analyzing the data, developing a conclusion, making decisions, and reevaluating patient outcomes.

QSEN (Quality and Safety Education for Nurses)

Initiated in 2005, and developed to help future nurses with knowledge skills, and attitudes to continue to improve the quality and safety of patient care.

Six initiatives of QSEN

1. Patient-centered care

2. Team-work and collaboration

3. Evidence-based practice

4. Quality improvement

5. Safety

6. Informatics

Five steps of nursing process

Assessment

-Data is collected, reviewed and analyzed

-Head to toe assessment, vital signs, direct and indirect questioning, medical record review, observation, obtaining a medication profile (included both prescription and OTC. compliance issues

-Objective data: Information gathered through senses (seen, heard. felt, smelled)

Subjective data: What the patient shares

Human needs statement

-Focuses on how the data collected signifies a problem, strength, or vulnerability

-Ex. “Risk for injury related to (R/T) lack of experience with medication regimen and second grade reading level as an adult as evidence by (AEB) inability to perform a return demonstration and inability to state common side effects

Planning: Outcome Identification

-outcomes are objective, measurable and realistic with an estavlished time period for achievement of the outcomes that are specifically stated on the outcome criteria

-Outcome criteria includes:

• Concrete descriptions of patient goals

• Expectations for behavior

• For drug therapy: our expected outcome is safe and effective administration of medications

Implementation

-Requires communication and collaboration with the patient, family, and healthcare provider team

-Consists of initiation and completion of specific nursing actions as defined by the Human Needs Statements, goals, and outcome criteria

-With medication administration you must be knowledgeable about your patient and the medication you are administering, and the medication safety rights

Evaluation

-Ongoing part of nursing proccess

-Includes monitoring for outcomes , the patients response to drug therapy, and any unexpected responses to therapy

-Documentation is very important it needs to be clear and concise

Medication Safety Rights

1. Right Drug

2. Right Dose

3. Right Time

4. Right Route

5. Right Patient

6. Right Documentation

Right reason

Does it make sense to give your patient based on their history. You must be knowledgable about the medication

Right response

Did the medication have its desired response

Ex. Your patient had high BP and we gave them a hypertensive. Did the BP drop?

Right to refuse

If a patient is refusing you need to find out why, educate, document, and notify physician.

Nurses are responsible for providing safe quality care to their patients

-Following the nine rights of medication administration to prevent medication error.