Chapter 1 THE NURSING PROCESS AND DRUG THERAPY

The Nursing Process 2 � A research-based organizational framework for professional nursing practice �

Five Steps of the Nursing Process 3 � Assessment � Nursing diagnosis � Planning

Classroom Response Question 5 The nurse answers a patient’s call light and finds the

Nursing Diagnosis 6 � Nursing diagnoses are used to communicate and share information about

Nursing Diagnosis 7 � Three-step process: Human response to illness, injury, or significant change

Planning 8 � Identification of goals and outcome criteria � Goals Objective, measurable, and

Classroom Response Question 9 The patient’s medication administration record lists two antiepileptic medications that

Implementation 10 � Initiation and completion of specific nursing actions as defined by the

The “Six Rights” of Medication Administration 11 � Right drug � Right dose �

Classroom Response Question 12 The day shift charge nurse is making rounds. A patient

Evaluation 13 � Ongoing part of the nursing process � Determining the status of

Classroom Response Question 14 A nurse makes an error when administering medications to a

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The Nursing Process 2 � A research-based organizational framework for professional nursing practice � Ensures the delivery of thorough, individualized, and quality nursing care to patients � Requires critical thinking � Ongoing and constantly evolving process Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Five Steps of the Nursing Process 3 � Assessment � Nursing diagnosis � Planning Goals Outcome criteria � Implementation including patient education � Evaluation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment 4 � Data collection, review, and analysis � Medication profile Any and all drug use Prescriptions Over-the-counter medications Vitamins, herbs, and supplements Compliance and adherence Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question 5 The nurse answers a patient’s call light and finds the patient sitting up in bed and requesting pain medication. What will the nurse do first? A. Check the orders and give the patient the requested pain medication. B. Provide comfort measures to the patient. C. Assess the patient’s pain and pain level. D. Evaluate the effectiveness of previous pain medications. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Diagnosis 6 � Nursing diagnoses are used to communicate and share information about the patient and the patient experience � Common nursing diagnoses related to drug therapy include: Deficient knowledge Risk for injury Noncompliance Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Diagnosis 7 � Three-step process: Human response to illness, injury, or significant change Factors related to the response (“related to”) Listing of cues, clues, evidence, or other data that support the nurse’s claim for the diagnosis (“as evidenced by”) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Planning 8 � Identification of goals and outcome criteria � Goals Objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria � Outcome criteria Concrete descriptions of patient goals Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question 9 The patient’s medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What will the nurse do? A. Give the medications PO with a small sip of water. B. Give the medications via the IV route because the patient is NPO. C. Hold the medications until after the test is completed. D. Call the health care provider to clarify the instructions. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Implementation 10 � Initiation and completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria � Independent, collaborative, dependent Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question 12 The day shift charge nurse is making rounds. A patient tells the nurse that the night shift nurse never gave him his medication, which was due at 2100. What will the nurse do first to determine whether the medication was given? A. B. C. D. Call the night nurse at home Check the medication administration record Call the pharmacy Review the nurse’s notes Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Evaluation 13 � 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question 14 A nurse makes an error when administering medications to a patient. Which action by the nurse requires the supervising nurse to intervene? The nurse A. B. C. D. completes an incident report. informs the prescriber of the error. documents adverse effects to the medication error. records completion of an incident report in the medical chart. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.