Fundamentals of Nursing

Patient Evaluation and Care

• Patients' conditions can change; re-evaluation is essential.

• Use objective data (like pain scales) to assess pain.

Pain Management

• Before administering medication, verify the physician's orders.

• Document pain relief intervention and re-evaluate pain levels after 30 minutes.

• Pain management schedules should respect dosage timing, typically every 4-8 hours or as prescribed.

Patient ID and Safety

• Wristbands with patient info are crucial (color codes indicate allergies).

• Identification methods include wristbands, ID cards, or printed labels.

Importance of Individualized Care

• Each patient is unique; consider allergies, cultural differences, and individual needs.

• Active communication and patient involvement in care are vital.

Regulatory Practice

• Nurses cannot self-administer drugs without a physician's order.

• All medications must be administered according to established guidelines.

Education and Patient Communication

• Ensure patient understanding of care plans and treatment.

• Respect religious views that may impact treatment choices.

Assessment Types

• Subjective data: patient-reported experiences (pain, feelings).

• Objective data: measurable signs (vital signs, lab results).

Goal Setting and Evaluation

• Goals for patients should be realistic, measurable, and time-limited.

• Regular review of medication effects and adaptations are necessary for effective treatment.

Documentation

• Maintain clear records of patient care and interactions.

• Use standardized formats for consistent data entry.