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125 Cards in this Set
- Front
- Back
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Five steps of nursing process |
Assessment nursing diagnosis planning implementation evaluation |
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Assessment |
Gathering data about the patient |
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What things should you gather when doing an assessment |
Information about the patient patient’s health history, lab values such as bloodwork and urine sample results signs and symptoms that the patient may be experiencing such as pain in ability to sleep etc., physical exam |
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Information gathered through assessment is described as |
Subjective data or objective data |
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Subjective data |
Refers to information given by the patient or family such as symptoms felt by the patient |
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Objective data |
Refers to measurable information that the nurse or healthcare provider can see such as blood pressure readings or crackles heard when listening to lungs with the stethoscope |
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Nursing diagnosis |
A conclusion about what a patient’s problem is.
In a way giving the nursing diagnosis is giving a name or label to a patient’s problem |
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Medical diagnosis |
The medical condition the patient has such as pneumonia or diabetes |
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Nursing diagnosis |
Identify as a specific part of that condition such as ineffective breathing or impaired mobility |
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Planning |
The part of the nursing process where the nurse plans care to try to help the patient overcome problems that have been identified |
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Implementation |
The step of the nursing process where the nurse carries out the plan |
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Evaluation |
During evaluation the nurse decides if the plan is working |
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What are RNs ultimately accountable for |
Planning care and implement patient care |
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What is the nurse practice act |
A legal document each state has that discusses patient care and identifies which part of patient care must be accomplished by an RN and which tasks may be delegated to the LPN |
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Who can administration of medications to patients be done by |
Both RNs and LPNs however, certain medications may only be administered by RNs |
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An example of drugs that can only be administered by RNs |
Chemotherapy drugs that are given for many types of cancers or intravenous medications that are injected directly into the vein |
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The nine rights of medication administration |
Right patient right drug right dose right route right time right documentation right reason right response right to refuse |
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Right patient |
Properly identifying the patient to ensure that the correct patient is receiving the medication |
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Right drug |
Ensuring that the correct drug is being given |
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Right dose |
The amount of medicine ordered for the patient |
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Right route |
How the drug is given: pill, injection, ointment, or vein |
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Right |
When the medication should be given: morning, bedtime, with a meal, on an empty stomach etc. |
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Right documentation |
Proper charting, Is the medication noted in the patient’s medical record so there’s proof that the patient received the drug? |
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Right reason |
Why is the patient receiving this drug? does this reason make sense for the patient? |
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Right to response |
How is the patient or the patient’s condition responding to the medication? Is the medication working as we expect it to work? |
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Right to refuse |
Patients have the right to refuse to take medication. In the event that a patient refuses however the nurse or healthcare provider should have the patient clarified the reason why they are refusing the medication and should provide education to the patient about the medication to ensure that the patient is making a well-informed decision to refuse the medication. The patient’s refusal of the medication must also be documented in the patient’s medical record |
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Therapeutic effects |
When the drug is doing what it was expected to do |
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Side effects |
Unintended but not unusual facts that may occur and some patients who are taking medication. |
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Adverse effects |
Effects that are seen with patients who do not respond to their medication in the way they should, or they develop new signs or symptoms that are attribute it to medication. Could be life-threatening |
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Nursing actions |
Specific tasks that are done with a specific purpose |
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Nursing process |
A plan that guides a nurses work and logical steps that has been used for decades |
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Front (Term) |
Back (Definition) |
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Front (Term) |
Back (Definition) |
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Legal and regulatory issues include |
Federal laws state laws hospital/healthcare facility policies governing who can administer medications and when and how medications may be given |
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What are laws and regulations governing medication administration’s meant to do |
Protect patients as well as to protect the licenses of healthcare providers who are involved in medication administration |
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What is the ultimate goal of medication administration policies and laws |
That the patients receive appropriate medication safely |
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Drug diversion |
Both a legal and ethical issue |
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Drug diversion definition |
The illegal transfer of regulated drugs such as narcotics from the patient for whom the drug is prescribed to another person , such as a nurse, for the nurses or others use |
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Federal laws |
Describe rules that control how certain drugs may be giving |
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State laws |
Describe who may prescribe, dispense, and administer or give medication |
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Individual hospital or agency rules three drug categories under US federal laws |
Policies about how and when medications are given, and how the records that record drug treatments are kept |
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Three drug categories under US federal |
Controlled substances, prescription drugs, over-the-counter medications |
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Controlled Substances |
Major painkillers, such as opioids, and some sedatives and tranquilizers |
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Who can order controlled substances |
Only people with a special license |
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Prescription drugs |
Use of drugs must be carefully controlled. it must be prescribed by an authorized healthcare professional such as a doctor, dentist, nurse practitioner |
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Over the counter medicationsPhysical dependence |
Drugs considered safe enough to be purchased without a prescription |
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Physical dependence |
Actual physical symptoms that occur during drug withdrawals such as shaking, increased heart rate , confusion , seizures, and other troubling symptoms |
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Psychological dependence |
Also known as addiction: mental desire associated with taking certain substances such as cocaine or alcohol
Symptoms such as anxiety anger or depression can occur |
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9 Rights of Drug Administration |
A series of nursing actions to protect the patient from drug error |
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Adverse Effect |
a drug effect that is more severe than expected and has the potential to damage tissue or causes serious health problems. |
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Other names for adverse effect |
- toxic effect - toxicity |
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Assessment |
The first step in the nursing program that involves gathering information about the patient that will be used in planning care |
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Contraindication |
a health-related reason for not giving a specific drug to a patient or group of patients |
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Diagnosis |
A name or label for the patient's disease or condition |
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Expected Side Effects |
Unintended but not unusual effects of the drug that occur in many people taking the drug; they are usually mild and do not require that the drug be stopped |
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Evaluation |
the process of determining the right response looking at what happens to the patient when the nursing care plan is put into action. - an appraisal of the treatment effectiveness |
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Healthcare Setting |
any setting in which the LPN/VN practices nursing |
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Identifiers |
information used to reliably prove an individual is a person for whom the drug treatment is intended. |
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What could an identifier be? |
- person's full name - person's medical record ID number - birth date - telephone number |
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Implementation |
the act of carrying out the planned interventions |
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Nursing Process |
a system to guide the nurse's work work in a logical way. |
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How many steps are in the nursing program, and what are they? |
5. 1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation |
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Objective Data |
information that can be seen, heard, felt, or measured by someone other than the patient |
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Planning |
Using information gathered in the nursing assessment about the patient to set short term and long term goals |
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Subjective Data |
reports of what the patient says he or she is feeling or thinks |
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Therapeutic Data |
the intended action of the drug, also known as the drug's beneficial outcome |
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as needed or "PRN" drug order |
an order for a drug to be given as needed based on a nurse's judgment or safety and patient need |
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Agonist |
the drug attaches at the receptor site and activates the receptor – the drug has an action similar to the body’s own chemicals |
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Partial Agonist |
the drug attaches at the receptor site, but only a slight (or partial) chemical action is produced. |
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Antagonist |
the drug attaches at the receptor site, but no chemical response is produced – the drug prevents (works against) activation of the receptor. |
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Absorption |
the way a drug enters the body and passes into the circulation. Absorption takes place through diffusion, filtration, and osmosis, which are all ways that molecules are distributed. Absorption depends on the solubility of the drug (the ability of the drug to dissolve), the route of administration (how the drug is given, such as by mouth, injection, intravenous, etc. – we will discuss routes of administration in a later chapter), and the degree of blood flow through the tissue where the medication is found (the higher the blood flow, the more rapidly absorption occurs |
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Distribution |
the way that drugs move, or are distributed, to their sites of action in the body. The bloodstream and lymphatic system usually carry drugs throughout the body. Several factors affect drug distribution – blood supply to organs; cell membranes with small passages, such as the placental barrier and the blood-brain barrier; types of tissue such as bone, fat, and muscle; chemical properties of a drug. |
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Metabolism |
the process where the body’s enzymes use the drug in chemical reactions, or how the body “breaks down” the drug. Metabolism is done primarily by the liver, especially when medications are given through the mouth (i.e., pills, capsules, liquids) |
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Biotransformation |
the process by which medication is gradually broken down through complex chemical reactions |
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Refers to the percentage of medication that is inactivated after it goes through the liver the first time |
first-pass effect |
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Excretion (elimination) |
the process where inactive chemicals, chemical by-products, and waste are discarded from the body |
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half-life |
refers to how long it takes to eliminate 50% of a drug from the body. The half-life of a drug helps determine the dosage, frequency of dosing, and duration (how long a drug will last). A drug with a longer half-life may only need to be taken once a day, while a drug with a shorter half-life may need to be taken more often. |
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Drug Actions |
Medications are given in hopes that the desired effect of the drug will occur. For example, if a patient has hypertension (high blood pressure) and that patient is given a medication to lower blood pressure, it is hoped that a decrease in blood pressure will indeed occur. It is also possible to predict how the medication will act in the body, and what the effects of the medication will be, based on the years of development and testing that go into making medications available for patient use. However, every individual is different, so sometimes different reactions may be seen. Patients should always be watched closely to monitor reactions to medications. |
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Desired action |
expected response of the medication- the medication does what is desired |
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Idiosyncratic responses |
strange, unique, or unpredicted responses to medication |
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Hypersensitivity |
increased reaction to a drug |
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Allergy |
sensitivity caused by antibody response to a drug |
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Anaphylactic reaction |
allergic reaction that is so severe, it is life- threatening |
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Bioequivalent |
products that are chemically the same or identical and so are interchangeable |
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Generic equivalents |
drug products are seen as identical with respect to their active ingredients |
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Additive Effect |
when two drugs are given together, and the combined effect of the drugs either makes one drug stronger or the action of the two drugs more powerful. |
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Antagonistic Effect |
when one drug interferes with the action of another drug |
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Displacement |
when one drug replaces another at the drug-receptor site, increasing the effect of the first drug |
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Incompatibility |
when drugs do not mix well chemically – attempting to mix them together in a syringe, for example, may cause a chemical reaction so neither of them can be given. |
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Synergistic Effect |
when the effect of two drugs taken at the same time is greater than the sum of the effects of each drug given alone. |
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Some personal Factors that influence drug therapy |
- hydration - blood flow status - use of other drugs or alcohol - liver or kidney problems - body size - lean- to - fat ratios - ethnicity - genetic makeup |
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Pediatric Drug Therapy Considerations: (Read pages 30-31) |
during childhood: - drug absorption - distribution - metabolism - excretion As children grow: - total body water decreases - body size increases - body fat stores increase |
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Teratogenics |
drugs that can harm the fetus (likely to cause malformations or damage in the embryo or fetus) |
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Routes of Administration refers to: |
the way medications are given |
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Enteral Routes |
directly into the GI tract |
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Parenteral Route |
injection into the dermal, subcutaneous, or intramuscular tissue, or into the bloodstream |
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Percutaneous Route |
absorption through the mucous membranes or skin |
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3 Routes |
- enteral -parenteral - percutaneous |
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The route determines: |
how quickly the medication will be absorbed by the body |
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What is the fastest route? |
Intravenous (IV) : the medication is administered directly into a vein, so it immediately enters the circulation |
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Enteral medications are given how? |
directly into the gastrointestinal (GI) tract |
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The enteral route includes : |
- oral - nasogastric ( NG) - rectal |
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NG tube |
a tube that leads from the patient's nose into the stomach. Liquid Feeding and medications are given through the NG tube |
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Most common Route of medication |
Through the moth |
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Most medication come in this form |
oral |
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Benefits of oral medication |
- easy for nurses to give and for patients to swallow - if a patient takes too much, the drug can be removed by pumping patient's stomach or inducing vomiting |
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Disadvantages of oral medication |
- can not be given to patients who are nauseated, vomiting, or unconscious - some chemicals are not effective if mixed with gastric secretions so not all meds may be appropriate in oral form |
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Onset of action |
how long it may take to begin working may be different from other drugs depending on how they are absorbed |
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Forms of oral medications |
- tablets (pills) - capsules - elixirs - emulsions - lozenges - suspensions - syrups |
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What special equipment may be needed for oral meds in liquid form? |
- measuring cup - medication spoon - med. dropper - syringe |
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Sustained-release (long-acting) |
long acting drugs arereleased over a longer period of time. Do notcrush these or allow the patient to chew them,as then the drug may be released too quicklyand the patient may receive too much drug toosoon. This could result in toxicity to thepatient. |
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How may liquid medications and crushed pills be given> |
NG or PEG tube |
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How does a NG work? |
An NG tube is passed through the nose intothe stomach. Patients who will be receivingfeedings or medications through a tube for along period of time may have a tube placeddirectly into the stomach through theabdominal wall. This is called a PEG tube(percutaneous endoscopic gastrostomy). |
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When may rectal administration be used |
when patient is vomitting |
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ex. of medication given via the rectal route |
suppository |
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where is medication inserted when using the rectal route |
medication is inserted into the rectum and left there to be absorbed |
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parenteral route |
refers to medications given into the tissues or bloodstream, usually through a needle |
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intradermal |
into the intradermal space ( between the upper two layers of skin) |
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Subcutaneous |
under the dermis |
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Intramuscular |
into the muscle layer |
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intravenous |
into the vein |
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When may the Parenteral Route be used |
- if the patient cannot take oralmedications (nausea, vomiting, is not able toeat yet following surgery, is comatose • Used when the action of the medication is requiredquickly (IV is especially used for this) • Used if medication is not available in enteralform or if gastric (stomach) enzymes mightdestroy the medication |
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Medications to be given via a parenteralroute will need to be |
“drawn up” –transferred from the vial or ampule thatthe liquid is in to a syringe for injection |
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P. R will require |
special equipment, such assyringes, needles, IV equipment |
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There are different types of syringes, such as |
insulin syringes tuberculin syringes syringes that measure liquids in milliliters. |
