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L EARNING O UTCOME 1
Compare and contrast the different steps of the nursing process.
Concepts
Review the steps of the nursing process: Assessment, diagnosis, outcome identification and planning, implementation, and evaluation.
Figure 6.1
The Nursing Process
L EARNING O UTCOME 2
Identify assessment data that is pertinent to medication administration.
Concepts
Assessment data that are pertinent to medication administration are health history information, physical assessment data, lab values and other measurable data, and assessment of medications’ therapeutic effects and side effects.
L EARNING O UTCOME 3
Develop appropriate nursing diagnoses for patients receiving medications.
Concepts
1.
Nursing diagnoses for drug administration are the same as diagnoses written for other patient conditionspecific responses. They may address actual problems; focus on potential, or risk, problems; or deal with maintaining the patient’s current level of wellness.
2.
Actual problems include the diagnostic statement, related factor or inferred cause, and evidence gathered to support the chosen statement.
3.
Risk problems include the diagnostic statement and a related factor, or inferred cause.
4.
Most common nursing diagnoses for medication administration are Knowledge Deficient and
Noncompliance.
5.
Nursing diagnoses applicable to drug administration are often collaborative problems that require communication with other health care providers.
6.
Table 6.2 provides a list of some of the North American Nursing Diagnosis Association (NANDA)— approved diagnoses appropriate to drug administration. Examples include Activity Intolerance, Risk for
Falls, Urinary Incontinence, and Oral Mucous Membrane Impaired.
Consult books on nursing diagnoses for more information.
Adams Ch 06-1

Table 6.2
Common Nursing Diagnoses Applicable to Drug Administration
L EARNING O UTCOME 4
Plan realistic goals and outcomes for patients receiving medications.
Concepts
1.
Goals based on the nursing diagnosis established from the assessment data should be realistic and focus on what the patient should be able to achieve and do. These goals should be prioritized and discussed with the patient or caregiver. Goals may be short term or long term depending on the setting and situation. Safe and effective administration of medications is the overall goal. Goals should focus first on the therapeutic outcomes of medications, then on the treatment of side effects.
2.
Outcomes provide the specific, measurable criteria that will be used to evaluate the degree to which the goal was met. Outcomes should be realistic and focus on what the patient will achieve or do. These outcomes should be discussed with the patient or caregiver. The written outcomes should include the subject, the actions required by the subject and under what circumstances, the expected performance, and the specific time frame in which the performance will be accomplished.
L EARNING O UTCOME 5
Discuss key intervention strategies to be implemented for patients receiving medications.
Concepts
1.
Interventions are aimed at returning the patient to an optimal level of wellness through the safe and effective administration of medications.
2.
Key intervention strategies include the five rights and the techniques of administering medications discussed in Chapter 3, monitoring drug effects, documenting medications, and patient teaching.
3.
Monitoring drug effects is a primary intervention. This includes identifying therapeutic effects, reassessing the patient’s physical condition, taking vital signs, determining body weight, checking lab values and/or serum drug levels, taking a statement from the patient, and monitoring side and adverse effects.
4.
Documentation is completed during the intervention phase. This includes documenting the when, where, and how of medication administration, both therapeutic and adverse effects; patient’s statements; and objective assessment data, such as vital signs.
5.
Patient teaching is a vital component of the interventions for the patient receiving medications. Knowledge deficit and noncompliance are directly related to the type and quality of medication education the patient receives. Elderly and pediatric patients present special challenges to patient teaching. The nurse may need to coteach the patient’s caregiver.
Table 6.3
Important Areas of Teaching for a Patient Receiving Medications
Ch 06-2 Adams

L EARNING O UTCOME 6
Evaluate the outcomes of medication administration.
Concepts
1.
Evaluation is a checkpoint when the nurse considers the overall goal of safe and effective administration of medications, with the best therapeutic outcome possible, and takes the steps necessary to ensure success.
2.
Evaluation begins a new cycle as new assessment data are gathered and analyzed, nursing diagnoses are reviewed or rewritten, goals and outcomes are refined, and new interventions are carried out.
Adams Ch 06-3