Chapter_01 Nursing Process(1)

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CHAPTER 1 The Nursing Process and Drug Therapy Presented to: Pharmacology 3342 Fall 2010 Texas A&M University – Corpus Christi

The Nursing Process: 

The Nursing Process A research-based organizational framework for professional nursing practice Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient Flexibility is important Requires critical thinking Ongoing and constantly evolving process

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Assessment Nursing diagnosis Planning Goals Outcome criteria Implementation Evaluation The finished process is a Nursing Care Plan

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Assessment Data collection Subjective, objective Medication history Prescriptions Over-the-counter medications Herbal therapies Responses to medications (therapeutic and adverse)

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Nursing diagnosis Decision about the need/problem of the patient (actual or at risk) Critical thinking, creativity, and accurate data collection NANDA-I format

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Nursing diagnosis Three steps Human response to illness (actual or at risk) “related to” “as evidenced by”

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Planning Identification of goals and outcome criteria Must be specific and measurable Must be patient-centered Time frame Prioritization

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Writing nursing interventions Based on evidence-based nursing Individualized to client

The Nursing Process (cont’d): 

The Nursing Process (cont’d) Implementation Initiation and completion of the nursing care plan as defined by the nursing diagnoses and outcome criteria Follow the “Six Rights” of medication administration

The Six Rights of Medication Administration: 

The Six Rights of Medication Administration Right drug Right dose Right time Right route Right patient Right documentation

Medication Errors: 

Medication Errors Six rights Major problem Definition Multiple reasons for occurrence Must be investigated to prevent future occurrences.

Evaluation: 

Evaluation Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patient’s response to drug therapy Expected and unexpected responses Clear concise documentation