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19 Cards in this Set
- Front
- Back
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Assessment (in Nursing Process)
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ongoing, initial assessment - baseline data both subjective (what client says or perceives) and objective data (through physical assessment).
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Nursing Diagnoses
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Provide the basis for establishing goals and outcomes, planning interventions, and evaluating the effectiveness of the care given. Note: Unlike medical diagnoses that focus on a disease or condition, nursing diagnoses focus on a CLIENT'S RESPONSE to ACTUAL OR POtential health and life processes. Focus is on CLIENT's needs, not the nurse's.
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North American Nursing Diagnosis Association defines nursing diagnoses as:
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(NANDA) Def: A clinical judgment about individual, family or community responses to actual or potential health/life processes. Per NANDA, nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for wh/ the nurse is accountable.
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Short or long term goals:
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are established that focus on what the client will be able to do or achieve, not what nurse will do.
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Outcomes
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Objective Measurement of short or long term goals. Prioritize to meet immediate needs first.
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Planning
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links strategies or interventions to established goals and outcomes. Formal WRITTEN process that communicates w/ all members of the healthcare team what the nurse will do to assist the client in meeting those goals.
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Interventions
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designed to meet the client's needs and ensure safe, effective care. (still using ongoing reassessments)
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Evaluation
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Nurse compares the data w/ established nursing diagnoses, goals and outcomes and begins the process of ____. Established nursing diagnoses are reviewed while taking into consideration the client's response to care. (The whole cycle continues w/ new data)
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Health History Assessment prior to drug administration
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Questions: Chief Complaint, allergies, past medical history, family history, drug history, health management, reproductive history, personal-social history(ex. religious, smoke, caffeine), health risk history (illicit drugs)
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Assessment for drug administration includes .. .
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ability of client to assume for self-administration of medication if necessary. After analyzing the assessment data, the nurse determines client-specific nursing diagnoses appropriate for the drugs prescribed.
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Actual Diagnoses contain . ..
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a third part - the evidence gathered to support the chosen statement.
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Two of the most common nursing diagnoses for medication administration are . . . .
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Knowledge, deficient and Noncompliance. It is important to take the time to assess both of these things, esp the noncompliance for reasons.
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Nursing plan of care goal . ..
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safe and effective administration of medications, with the optimum therapeutic outcome possible
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Goals should focus first on .. .
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therapeutic outcomes of medications, then on the treatment of side effects
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OUtcomes are the specific criteria used to measure attainment of the selected goals.
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Written to include: the subject (client), actions required by the subject, under what circumstances, expected performance, and sp. time frame in wh/ performance will be accomplished. ex. actions (demonstrate injection), circumstances (using a preloaded syringe), performance (SC injection into the abdomen), and time frame (2 days fr. now -1 day before discharge home). Writing specific outcomes also gives the nurse a concrete time frame to work toward assisting client to meet goals.
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After goals and outcomes are identified based on the nursing diagnoses,
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A plan of care is written
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After plan of care is written - the implementation happens. _______ are aimed at returning client to an optimum level of wellness and limiting adverse effects related to client's medical diagnosis or condition.
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Interventions (including 5 rights of drug administration and techniques of administering medications)
Include 1. monitoring drug effects 2. client teaching about drug 3. documenting medications |
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_______is a primary intervention that nurses perform. 1st - looking for identified therapeutic effects. Also monitors for adverse effects (and attempts to prevent or limit these effects when possible). Some can be managed by the nurse - others by Dr. or nurse practitioner. Documentation of all - good or bad results!
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Monitoring drug effects
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State nurse practice acts and regulation bodies such as JCAHO consider ___ to be a primary role for nurses, giving it the weight of law and key importance in accreditation standards. Safe administration with best therapeutic outcomes - goal of pharmacotherapy.
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Teaching
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