NURSING PROCESS iii.

Client’s compliance with the

treatment regimen
- The foundation of the nursing practice follows a
iv. Allergic reactions to medications
systematic guide ensuring the quality of care being
v. Use of herbal or recreational drugs
delivered to our patient
vi. Lifestyle and behavior
- An organized, systematic manner of providing goal-
vii. Alcohol consumption and usage of
oriented and humanistic care that is both efficient
cigarettes
and effective
viii. History of compliance
- ADPIE
ix. Ability to perform activities of daily
living
x. Check dietary patterns, cultural, and
socioeconomic status
xi. Check psychological and mental
status
2) Objective (signs)
 information observed by the nurse with the
use of 5 senses
 physical assessment (cephalocaudal)
 quantifiable e.g. laboratory and diagnostic
examination or result
Purpose of Nursing Process
Types of Assessment
 Defines patient goals
 Determines the nurse’s role Initial - Involves the client’s perception of
 Provides consistency of care comprehensive her health of all body parts or
 Customize care interventions assessment systems, past health history,
family history, and lifestyle and
 Promotes holistic treatment
health practices that includes
 Provides quality patient care
subjective and objective data
ASSESSMENT gathered during a step-by-step
physical examination
- a systematic, organized, collection of data about the
- Happens upon initial interaction
patient
with the patient
- will serve as the baseline data for determining the
Partial or - Occurs after the ICA is established
treatment course the patient is to undergo and to
Ongoing - Any problems that were initially
evaluate the effect of the treatment employed in
assessment detected in the client’s body
relation to the patient’s condition
system or holistic health
Types of Data patterns are reassessed to
determine any changes
1) Subjective (symptoms) – given verbally by the (deterioration or improvement)
patient - Consists of a mini overview of the
a. Current health history – COLDSPA client’s body system and holistic
b. Clinical symptoms verbalized by the health
patient
Focused or - A thorough assessment of the
c. Current medication Problem- client’s particular problem
i. Medication reconciliation
Oriented - does not cover areas not related to
ii. Medication review Assessment the problem
Emergency - A very rapid assessment
assessment performed in life-threatening
situations
- ABC or CAB (airway, NURSING DIAGNOSIS
breathing, circulation)
- shows actual and potential alterations in the patient’s
function based on the assessment of the clinical
STEPS ON HEALTH ASSESSMENT situation
- the clinical act of identifying problems
1) Collection of data – interview, observation, - means to analyze assessment information and derived
laboratories and diagnostics
meaning from this analysis
- PURPOSE: to identify the patient’s health care needs
2) Validation of data
and to prepare diagnostic statements
- a method of confirming if the data collected
is reliable and accurate Actual nursing - state of existing health problems
diagnosis - ex: Fatigue r/t increase job
THINGS TO DO:
demands and personal stress
o Recheck your own data through re- AMB/AEB client’s statement of
assessment feeling exhausted and inability
o Clarifying data by asking the client to perform unusual work and
additional questions home responsibilities
o Verify data with another healthcare Wellness or - client verbalizes desire to increase
professional Health well-being and actualize human
o Compare your subjective and objective Promotion health potential
data to verify discrepancies Nursing - ex: Readiness for enhanced sleep
Diagnosis pattern r/t expressed desires to
3) Organization of data – components of a nursing learn ways to stay asleep
health history or Gordon’s 11 functional health throughout the night
patterns Risk Nursing - the situation in which the client is
Diagnosis vulnerable to an actual
4) Documentation of data diagnosis that will most likely
- Anything that is not documented is not occur if the nurse does not
considered done or performed intervene
- ex: Risk for Infection r/t post
REMINDERS:
debridement of the wound of
o Document legibly or print neatly in non- right gluteal area AEB moist
erasable ink dressing
o Use correct grammar and spelling. Use only
approved abbreviations (based on hospital
PLANNING
policy)
o Avoid wordiness that creates redundancy - process of formulating and documenting measurable,
o Use phrases instead of sentences realistic client-focused goals which will provide a
o Record data findings, not they were obtained. basis for evaluating the nursing diagnosis
Write entries objectively. - determining beforehand the strategies or course of
o Record the client’s understanding of problems actions to be taken before implementation of
o Specifically, record the data findings nursing care
  Example: After 2 hours of nursing - to carry out planned nursing interventions to help the
interventions, the patient will be able to patient attain an optimal level of health
demonstrate proper administration of the
Requirements for implementation:
prescribed dose of insulin.
- The nurse also formulates instructional objectives and 1) Knowledge – intellectual skills
designs client education programs to assist 2) Technical skills – in carrying out treatments or
individuals in the self-administration of drugs procedures
Focuses on the following: 3) Communication skills – through the therapeutic
use of self
 Why the drug is needed
PROCESS IN IMPLEMENTATION
 How the drug is to be administered
 Common indications of adverse reaction  Reassessing
 Best schedule to administer the drug  Determining the nurse’s need for assistance
 Drug interaction and setting priorities
 Performing nursing interventions and
Purpose
supervising the delegated care
 Identify goals and nursing interventions  Recording and documentation of actions
 Provide direct patient care activities
3 Types of Interventions Frequently Involved in
 Promote continuity of care
Drug Therapy
 Allow for delegation of specific activities
1) Proper drug administration – DTR of medication,
ACTIVITIES IN PLANNING
preparation of medication, and documentation of
1) Identify the goals administration
a. Short-term goals can be within days or 2) Comfort Measures – relieving the pain and
discomfort felt by the patient
weeks
3) Patient and Family Education
b. Long-term goals require more time
such as several weeks or months EVALUATION
2) Planning nursing interventions
- assess the effectiveness of the interventions performed
 To direct activities to be carried out in
and whether or not the plan is achieved
the implementation phase
- assessment of the patient’s response to nursing
 Can be independent, dependent, and
interventions
interdependent in nature
- comparison of the response to predetermined
3) Writing a plan of care
standards or outcome criteria
 The blueprint of the nursing process
 Should be nursing-centered and PROCESS
patient-centered
 Each should be supported by a scientific  Collect data about the patient’s response
rationale  Compare the gathered data to goals and
outcome criteria
IMPLEMENTATION  Analyze reasons for the outcomes
- putting the plan into action to accomplish the  Modify the plan as needed
established goals or expected outcomes  It may be completely met, partially met, or
- includes the nursing actions necessary to achieve its completely unmet
goals and reinforce the client’s education, which is  New problems or nursing diagnoses have
the primary duty of the nurse developed
In order to properly perform the evaluation, you 1. Right assessment
should know the following:  secure a copy of the client’s history of drug
interactions and allergies
 What therapeutic effects should the drug  some medication requires a specific
produce assessment prior to administration
 What adverse reactions is the drug known to  e.g. respiration rate, pulse rate, blood
cause pressure, and/or laboratory results
 By what mechanisms of action does the drug
work 2. Right patient
 What should the patient know about the drug  ask the name of the client and check his/her
 Which therapeutic effects has the drug ID band before giving the medication
produced for the patient: If none or its effect  even if you know the patient’s name, you
has been insufficient, what issues may be still need to ask just to verify
involved
Identifying the patient

 Check wrist identification band

RIGHTS IN GIVING MEDICATIONS:  Ask patient to state their name and date of
MEDICATIONS DOs AND DONTs birth
RESPONSIBILITIES OF THE HEALTH CARE
PROVIDER 3. Right to refuse medication
 adult clients have the right to refuse any
 Adequate, up-to-date information about all medication (autonomy)
medications to be administered  explain risks to patient’s refusal and
 Wisdom and judgment to accurately assess the reinforce the reason for medication
patient’s needs for medications, evaluate the  proper documentation and referral to the
response to medications and plan appropriate health care team
interventions as indicated
 Patient education to provide the necessary 4. Right to education
information to the patient and family about why,  educate the client regarding the therapeutic
how, and when medications are to be administered purpose and possible side effects of the drug
and potential side effects and precautions with  any diet restrictions or requirement
administration by the layperson  skill of administration
o Make sure to level your explanation with  laboratory monitoring
the client’s understanding 
 Skill in accurate delivery of the medication in the 5. Right drug
best interests of the patient, and with adequate  the patient receives the drug that was
documentation prescribed
 check and verify if it’s the right name and
Requirements form
 beware of look-alike and sound-like
 Familiarity with the medication
medication names (misreading medication
 Plan effective and efficient nursing with names that look similar is a common
competency and organization mistake, these look-alike medication names
 Technical skills and know-how may also sound alike and can lead to errors
 Educate the patient about the medication associated with verbal prescriptions)

10 R’s of Medication Administration

 Prescriptions – for institutionalized patients 7. Right route
(telephone or verbal order)  Give the medication by the ordered route
Drug order – prescribed by a physician, veterinarian,  Enteral (oral), parenteral (injectable), and
or licensed health care provider other routes
 Route of administration effects vary
COMPONENT OF A DRUG ORDER o Degree of absorption, speed of drug
1) Date and time the order is written action, side effects
2) Drug name (generic preferred) o The physician’s order specifies the
3) Drug dosage route of administration
4) Route of Administration o Route may not be changed without the
5) Frequency and duration of administration physician’s order
6) Any special instructions for withholding or
adjusting dosage based on effectiveness or 8. Right to refuse medication
laboratory results  Time at which the drug should be
 e.g.: May start antibiotic regimen after administered
Culture and Sensitivity (C&S).  Check the order for when it would be given
7) Physician or provider’s signature or name if and when was the last time it was given
TO/VO (telephone or verbal order)  For maximum effectiveness, drugs must be
8) Signature of licensed practitioner taking TO/VO
given on a prescribed schedule
TO AVOID ERRORS, the drug label should be
NOTE: Medication that was not taken at the supposed
read THREE TIMES
time can still be given at least 30 minutes before or
1) At the time of contact with the drug bottle or after the actual time but have it documented and the
container reason for doing so.
2) Before pouring the drug
3) After pouring the drug
9. Right evaluation
Note: Health care providers should be aware that  Patient’s response to the medication
certain drug names sound alike and are spelled similarly  Conduct appropriate follow-up
o Was the desired effect achieved or not?
Examples: Digoxin – Digitoxin, Quinidine - Quinine, o Did the client experience any side
Keflex – Kantrex, Demerol – Dicumarol effects or adverse reactions?

6. Right dose and dosage 10. Right documentation

 Check the medication sheet and the doctor’s  Include the name of the drug, dosage, route,
order before medicating date and time, nurse’s signature, and
o Be aware of the difference between an patient’s response
adult and a pediatric dose  No advance charting
 The dose ordered is appropriate for the  Not documented = not done
client
MEDICATION Dos
 Give special attention if the calculation
indicates multiple pills/tablets or a large 1) Do find time to know more about the drug your
quantity of a liquid medication patient is receiving
o this can be a cue that the math 2) Do check the written order for completeness
calculation may be incorrect: double- and accuracy
check calculations that appear 3) Do give medications at designated times
questionable
 4) Do keep the medication card with you as you 13) Don’t call the client’s name as the sole means of
are preparing the patient’s medication identification
5) Do observe sterile technique in the preparation 14) Don’t give the drug if the client states that the
and administration of parenteral medications drug is different from the drug he/she has been
6) Do ask another nurse or your superior to check receiving. Recheck the order and the
your computation before you prepare the drug medication first
7) Do be sure your equipment is in good working 15) Don’t recap needles. Observe the universal
condition precaution
8) Do shake the bottle containing liquid 16) Don’t prepare the medications way ahead of
medication (especially if it is a suspension) the time they are to be administered
9) Do ask the patient’s name. Do not rely on his
room and bed number
10) Do stay with the patient until he has taken his
medication. Do not leave the medication on the
table when he says “I’ll just take it later”
11) Do observe the patient for any reactions of the
drug he has received
12) Do record (and report) the patient’s refusal to
take his medications
13) Do chart a medication only after you have
administered it

MEDICATION DON’Ts

1) Don’t be distracted when preparing

medications
2) Don’t accept verbal orders except in
emergencies
3) Don’t administer medications that somebody
else has prepared
4) Do not pour drugs from one container with
labels that are difficult to read or whose labels
are part
5) Don’t transfer drugs from one container to
another
6) Don’t push drugs into your hands
7) Don’t guess about drug dosages. Ask when in
doubt; your question may save a patient’s life
8) Don’t give medications for which the expiration
date has passed
9) Don’t use drugs that have sediments, are
discolored, or are cloudy
10) Don’t leave medications by the bedside or with
visitors
11) Don’t leave prepared drugs out of sight
12) Don’t give drugs if the patient says he/she has
allergies to the drug or drug group