Chapter 1
The Nursing Process
and Drug Therapy
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
The Nursing Process
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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.
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Five Steps of the Nursing Process
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Assessment
Nursing diagnosis
Planning
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Goals
Outcome criteria
Implementation including patient education
Evaluation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Assessment
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Data collection, review, and analysis
Medication profile
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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.
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Classroom Response Question
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.
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Nursing Diagnosis
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Nursing diagnoses are used to communicate and share
information about the patient and the patient experience
Common nursing diagnoses related to drug therapy
include:
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Deficient knowledge
Risk for injury
Noncompliance
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Nursing Diagnosis
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Three-step process:
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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.
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Planning
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Identification of goals and outcome criteria
Goals
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Objective, measurable, and realistic with an established time
period for achievement of the outcomes that are specifically
stated in the outcome criteria
Outcome criteria
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Concrete descriptions of patient goals
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Classroom Response Question
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.
9
Implementation
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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.
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The “Six Rights” of
Medication Administration
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Right drug
Right dose
Right time
Right route
Right patient
Right documentation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Classroom Response Question
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.
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Evaluation
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Ongoing part of the nursing process
Determining the status of the goals and
outcomes of care
Monitoring the patient’s response to drug therapy
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Expected and unexpected responses
Clear concise documentation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Classroom Response Question
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.
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