Pharm review Chapter 6

CJMM

Builds on the nursing process and encourages the nurse to shift to clinical reasoning and judgement in decision making

Nursing process steps

ADPIE

Assessing

Diagnosing

Planning

Implementing

Evaluating

Assessment of patient

• systemic collection, organization, validation, documentation of patient data

Subjective data

What patient describes

Objective data

Physical assessment, lab tests, other diagnostic sources

Assessment

focuses on reaction to medication

• desired response

• Adverse effects

• Patient capability of assuming responsibility for self administration

Nursing diagnoses

Clinical judgement of the patient’s actual or potential health problem that is within the nurse’s scope of practice to address

Areas of concern (diagnosis)

• promoting therapeutic drug effects

• Minimizing adverse drug effects and toxicity

• Maximizing patient ability for self-care

Planning

Prioritizes diagnoses, formulates desired outcomes, and selects nursing interventions that can assist patient to establish optimum level of wellness

Goals of establishment

• safe and effective administration

• Therapeutic outcome

• Treatment of side effects

Goals of establishment

• safe and effective administration

• Therapeutic outcome

• Treatment of side effects

Implementation

Executing the planned nursing interventions & care activities

• Nurse applies knowledge and skills to move patient toward desired goal and optimal wellness

Evaluation

Assessing the patient’s progress to determine if the established goals/outcomes were met

Action of implementation

Administering the drug, providing patient teaching and initiating other specific actions in plan of care

Monitoring drug effects requires through knowledge of the actions of each medication

Documentation