CHAPTER 1 THE NURSING PROCESS AND DRUG THERAPY

CHAPTER 1 – THE NURSING PROCESS AND DRUG THERAPY

The Quality and Safety Education for Nurses (QSEN) Project • Initiated in 2005 • Preparing future nurses with the knowledge, skills, and attitudes (KSAs) needed to continuously improve the quality and safety of patient care within the health care system • KSAs flow out of the QSEN initiatives and are being integrated into nursing education curricula and clinical outcomes.

Six Major Initiatives of QSEN • Patient-centered care • Teamwork and collaboration • Evidence-based practice (EBP) • Quality improvement (QI) • Safety • Informatics

The Nursing Process • 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

Five Steps of the Nursing Process • Assessment • Nursing diagnosis • Planning

• Goals
• Outcome criteria

• Implementation, including patient education • Evaluation

Assessment • Data collection, review, and analysis • Medication profile

• Any and all drug use
• Prescriptions
• Over-the-counter medications
• Vitamins, herbs, and supplements
• Compliance and adherence

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?

• Check the orders and give the patient the requested pain medication.
• Provide comfort measures to the patient.
• Assess the patient’s pain and pain level.
• Evaluate the effectiveness of previous pain medications.

Correct answer: C

Rationale: The nurse should always assess a patient before any intervention. Although the nurse will check the orders and possibly give the medication (and possibly even perform the actions in responses B and D), the first priority is assessment.

North American Nursing Diagnosis Association International (NANDA-I) • Purpose of NANDA-I: increase the visibility of nursing’s contribution to the care of patients and to further develop, refine, and classify the information and phenomena related to nurses and professional nursing practice • See Box 1-2 for more information about the 2012 to 2014 NANDA-approved nursing diagnoses.• See Box 1-3 for a listing of NANDA-approved nursing diagnoses (2012-2014) most relevant to drug therapy.

Nursing Diagnoses • Nursing diagnoses are used to communicate and share information about the patient and the patient experience.

• Common nursing diagnoses related to drug therapy include:

• Deficient knowledge
• Risk for injury
• Noncompliance

• Three-step process:

• 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”)

Planning • Identification of goals and outcome criteria • Goals

• Objective, measurable, and realistic with an established time period for achievement of the outcomes that

are specifically stated in the outcome criteria • Outcome criteria

• Concrete descriptions of patient goals

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?

• Give the medications PO with a small sip of water.
• Give the medications via the IV route because the patient is NPO.
• Hold the medications until after the test is completed.
• Call the health care provider to clarify the instructions.

Correct answer: D

Rationale: The dosage for the IV route would not be the same as for the PO route. Holding the medications may cause drug levels to drop and result in seizure activity, and giving the medications PO without consent may alter the test results. The nurse must never assume the route of medication administration and should consult the physician for clarification of the orders.

Implementation • Initiation and completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria • Independent, collaborative, and dependent

The “Six Rights” of Medication Administration • Right drug • Right dose • Right time • Right route/form • Right patient • Right documentation

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?

• Call the night nurse at home.
• Check the medication administration record.
• Call the pharmacy.
• Review the nurse’s notes.

Correct answer: B

Rationale: The medication administration record is the legal documentation that the professional nurse uses to sign off medications that are given, so it should be checked first.

Evaluation • Ongoing part of the nursing process • Determining the status of the goals and outcomes of care • Monitoring the patient’s response to drug therapy • Expected and unexpected responses • Clear, concise documentation

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

• 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

Correct answer: D

Rationale: If there is a medication error, the nurse should complete an incident report with the entire event, surrounding circumstances, therapeutic response, adverse effects, and notification of the prescriber described in detail. However, the nurse should not record completion of an incident report in the medical chart.