Chapter 4 : The Nursing Process and Patient Safety

Assessment

Gathering information about the patient's health, history, and environment.

Nursing Conclusion

Judgment about actual or potential patient problems based on assessment.

Planning

Setting goals and deciding on interventions to help the patient achieve health outcomes.

Intervention

Taking actions like giving meds, teaching, or providing comfort.

Evaluation

Reviewing patient outcomes to determine if the plan worked or needs to change.

Nursing Process

Step-by-step method: Assessment, Conclusion, Planning, Intervention, Evaluation.

Patient-Centered Care

Focus on treating the whole person, not just the disease.

Health Trends

People live longer, use more meds, and go home sooner from hospitals.

Technology in Healthcare

Brings more tests, treatments, and new drugs, requiring constant updates.

Nursing Role

Includes assessing, intervening, educating, and evaluating care for patients.

Medication Laws

Nurses must understand legal guidelines for giving drugs.

Drug Knowledge

Nurses must know what the drug does, how it works, and who should/shouldn’t get it.

Whole Person Care

Includes physical, emotional, spiritual, cultural, and family health.

Assessment - History

Looks at conditions, drug use, allergies, education, finances, and support system.

Assessment - Physical

Checks weight, age, kidney/liver function, and drug-related symptoms.

Ongoing Assessment

It never stops—nurses must constantly adjust to patient changes.

Importance of Assessment

Helps avoid drug side effects and improves safety.

Right Patient

Verify identity with name, DOB, and wristband. Check allergies.

Right Drug

Double-check name; avoid confusion with similar names.

Right Storage

Store correctly—some drugs need refrigeration or protection from light.

Right Route

Give drug by correct method—pill, IV, injection, etc.

Right Dose

Check dose calculations, avoid decimal errors, and validate before giving.

Right Preparation

Mix, crush, or reconstitute properly if required.

Right Time

Give drugs on schedule, note food or timing instructions.

Right Recording

Document only after giving medication, not before.

8 Rights of Medication Administration

Patient, Drug, Storage, Route, Dose, Prep, Time, Recording.

Medication Error Causes

Increased meds, quick discharges, OTC/herbal use increase risks.

Who Checks for Errors

Prescriber, pharmacist, and nurse all serve as checkpoints.

Nurse as Final Check

The last person to verify meds before giving them.

Patient Role

Patients must know their meds, ask questions, and report issues.

Tools for Patients

Use pillboxes, apps, and written lists to track meds.

Storing Meds Safely

Keep dry, cool, and out of reach of kids and pets.

Teaching About Side Effects

Nurses educate patients on what to watch for.

Helping with Side Effects

Make patient comfortable; manage symptoms.

Child Medication Safety

Use proper tools, no adult meds, no calling it 'candy'.

Reporting Errors

Report to ISMP, FDA MedWatch, or facility’s system.

Nurse Teaching Role

Show how to take meds, avoid interactions, and promote safety.

Step 1: Assessment

Collect all facts: history, physical exam, and personal factors.

Step 2: Nursing Conclusion

Determine the most important issues based on assessment.

Step 3: Planning

Set goals and choose the best ways to meet them.

Step 4: Intervention

Take action—administer drugs, provide care, teach.

Check results and adjust care plan as needed