Pharmacology / Chapter 4: The Nursing Process and Pharmacology

Maslow's Hierarchy

(level 1) Physiological (level 2) Safety and Security (level 3) Belongingness and Love (level 4) Self Esteem (level 5) Self Actualization

The nurse can use primary, secondary, and tertiary sources to gain information to complete the medication history. When the nurse obtains vital signs to use as monitoring parameters later, it is considered which source of information?

- A primary source of objective data.

When is the nurse supposed to use the evaluation step of the nursing process?

- After each intervention.

When discussing the medication history with a patient, the nurse will ask the patient to identify current medications and drug allergies, as well as what other important factors?

- Any OTC medications used. - Any herbal products used. - Any street drugs used.

The nurse is preparing to administer morning medications. What actions does the nurse implement to identify the patient before administering medications?

- Asks the patient his/her name and birth date. - Checks the patient's identification band.

Why is it important for nurses to include the patient and appropriate significant others in decision-making when formulating therapeutic patient outcomes?

- Because it will help to promote cooperation and compliance by the patient.

The goal of evidence-based practice is to improve patient outcomes by using what?

- Best practices that evolved from research.

Nurses use the nursing process to:

- Build a framework for consistent nursing actions.

How will the nurse identify the therapeutic outcomes of the medications during the planning phase of the nursing process?

- By reviewing the drug monograph for common and serious adverse effects. - By identifying the therapeutic intent of the medications. - By educating the patient how to self-administer medications. - By identifying the recommended dosage of the medications.

The medication history that the nurse records includes which important facts to note?

- Current medications being taken by the patient and drug allergies.

The nurse analyzes the data collected from the patient assessment to identify signs and symptoms that will be addressed under the nursing diagnosis. These are known as the:

- Defining characteristics.

Which type of nursing action occurs when the nurse administers a medication to a patient?

- Dependent.

When formulating the nursing diagnosis in relationship to medications, the nurse will need to identify problems related to medication therapy and should review the:

- Drug monographs.

Discontinuing the use of antiembolism stockings because recent studies have shown them to be ineffective is an example of:

- Evidence-based nursing practice.

A patient develops edema as an adverse effect to a prescribed medication. A gain of 5 pounds has occurred in 24hrs, and 2+ edema is present in the legs. What nursing diagnosis statement does the nurse allocate to the patient?

- Excess fluid volume related to medication therapy, manifested by 5-pound weight gain and leg edema.

The nurse considers the patient's psychosocial and cultural needs during which step of the nursing process?

- Implementation.

What statement about critical care pathway is true?

- It is a standardized care plan derived from "best practice" patterns.

Information that is considered objective data?

- Laboratory results.

Which two types of nursing diagnoses apply to all types of medication therapies?

- Noncompliance and Deficient knowledge.

What does NANDA stand for when referring to nursing diagnoses?

- North American Nursing Diagnosis Association.

What is the NMDS classification system?

- Nursing Minimum Data Set

Nursing Classifications Systems

- Nursing Minimum Data Set (NMDS) - Nursing Interventions Classifications (NIC) - Nursing Outcomes Classifications (NOC) Designed to provide a standardized language for reporting and analyzing nursing care delivery that has been individualized for the patient.

What correctly distinguishes a nursing diagnosis from a medical diagnosis?

- Nursing diagnosis refers to the patient's ability to function in activities of daily living.

What is the difference between nursing interventions and expected outcome statements?

- Nursing interventions are actions statements, and expected outcome statements are what should be observed in the patient after specific actions.

What are the sources that the nurse uses to obtain a medication history?

- Objective data. - Other healthcare professionals. - Subjective data. - The electronic medial record.

Nursing interventions identify specific nursing actions, while measurable goal statements identify specific:

- Patient behaviors.

Which level of Maslow's hierarchy would be a priority when planning nursing care?

- Physiologic needs.

The use of evidence-based practice to guide the formulation of nursing interventions based on research and clinical expertise is part of what component of the nursing process?

- Planning

Which step of the nursing process is used when the nurse identifies the therapeutic intent of a prescribed medication?

- Planning

The nurse uses which step of the nursing process to detect any potential complications?

- Planning.

An important aspect of the nursing process is that it uses which approach?

- Problem-solving.

Which type of nursing diagnosis involves the potential for a complication of drug therapy?

- Risk/High-Risk Diagnosis

What phase of the 5-step nursing process is diagnosis?

- Second.

Gordon's Functional Health Patterns model is an example of what kind of assessment?

- Sociocultural, psychological, spiritual, and developmental approach.

How do nursing diagnoses differ from medical diagnoses?

- The medical diagnosis identifies alterations in structure and function.

When writing the outcome statements for medication therapy, the nurse will describe the expected outcomes from the prescribed medications based on what?

- The noted improvements of the symptoms present.

The nurse is performing an interdependent nursing action:

- The nurse is assisting the physical therapist with exercises for the patient.

Which four phases are included in the process used for planning patient interventions?

- The nurse sets priorities. - The nurse develops measurable goals. - The nurse formulates nursing interventions. - The nurse formulates therapeutic outcomes.

The nurse understands it is important to know the difference between a nursing diagnosis and a medical diagnosis because of what factor?

- The nursing diagnosis refers to how the patient is responding to an illness identified in the medical diagnosis.

The nurse is performing an independent nursing action:

- The patient is being monitored for the effects of the medication given at 8am. - The nurse is educating the patient in the use of the incentive spirometer. - The nurse is assessing the patient for bowel sounds after surgery.

The nurse is performing a dependent nursing action:

- The patient is given her 8am medication by the nurse.

What assessment finding is considered primary, objective information?

- The patient states that his temperature has been 98.8 F.

What is a measurable goal statement for a patient taking insulin injections?

- The patient will be able to self-administer insulin injections 2 weeks after initial training.

Nurses perform the task of patient assessment to determine:

- The patient's response to treatments. - Any adverse effects of medications. - If the patient has any risk factors.

When the nurse decides that the patient needs to rest before ambulating, the decision is based on what factor?

- The prioritization of physiologic needs.

The nurse needs to assess the patient in the hospital for therapeutic effects, side effects, and potential drug interactions during which time?

- Throughout the hospitalization.

When nurses use evidence-based practice changes for planning nursing care, they are incorporating what factor into the nursing process?

- Validated research.

Important healthcare information that the nurse gathers during the assessment of a patient includes which components?

- Vital signs. - Mobility level. - Family support.

When is Maslow's hierarchy of human needs used in the planning process?

- When setting priorities.

Drug History

Essential during your assessment of patient: 1. To evaluate the patient's need for medications. 2. To obtain current/past use of OTC medications, prescription medications, herbal products, and street drugs. 3. To Identify problems related to drug therapy. - Identify Risk Factors such as allergies to certain medications and the presence of other diseases that may limit the use of certain types of drugs.

Nursing Diagnosis

Provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. - Identify defining characteristics, high-risk factors, or problems. - Perform focused assessments - Formulate nursing diagnosis statements - Identify and seek orders/directions from appropriate health team members for collaborative problems. (Second phase of nursing process)

Nursing Process

The foundation for the clinical practice of nursing. - Provides the framework for consistent nursing actions and involves the use of a problem-solving approach rather than an intuitive approach. 5 Step Process: Assessment Nursing Diagnosis Planning Implementation Evaluation

Evaluation

The nurse determining whether the expected outcomes were met. - Evaluated by comparison with established nursing diagnoses, planned nursing actions, and the anticipated therapeutic outcomes. - Provides a means for the input of new significant data that indicate the development of additional problems or lack of therapeutic responsiveness. (Final phase of nursing process)

Implementation

The process of carrying out the established plan of care. (Fourth phase of nursing process)

Focused Assessment

The process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis.

Therapeutic Intent

Why the drug was prescribed and what symptoms will be relieved.

Evaluating Therapeutic Outcomes Procedure

1. Assessing patient responses to medications. 2. Determining signs and symptoms of recurring illnesses. 3. Assessing any adverse side effects. 4. Determining the patient's ability to receive education and self-administer medication, as well as the potential for compliance.

The nurse applies the nursing process by gathering patient information to assess the patient using which methods?

1. Body Systems Assessment 2. Head-To- Toe Assessment 3. Gordon's Functional Health Patterns Model

An example of independent nursing actions?

1. Educating a patient on correct coughing and deep-breathing exercises. 2. Obtaining the patient's medication history. 3. Documenting assessments of a patient's lung sounds.

Planning Procedure

1. Identify therapeutic intent and common/adverse effects. 2. Confirm recommended dosage and route of medication. 3. Check that scheduling of administration of medicine is based on the provider's orders. 4. Teach patient to keep written records of responses to prescribed medications. 5. Teach patient techniques of self-administration as needed. 6. Teach patient proper storage and refilling of medications.

What are the three components of the nursing diagnosis?

1. NANDA-approved label. 2. Defining characteristics. 3. Contributing factors.

Independent Nursing Action Procedure

1. Verify all aspects of the medication order before preparation. 2. Select correct supplies 3. Collect appropriate data to serve as baseline for later assessments. 4. Administer medication by correct route/site. 5. Document all aspects of medication administration. 6. Implement actions to minimize common side effects and adverse effects. 7. Educate the patient on medications and gaining their cooperation.

Health Promotion and Wellness Diagnosis

A clinical judgement about an individual, a family, or a community in transition from a specific level of wellness to a higher level of wellness.

Risk/High-Risk Diagnosis

A clinical judgement that an individual, a family, or a community is more susceptible to the problem than others in the same or a similar situation. - Supported by risk factors that contribute to increased vulnerability.

Syndrome Diagnosis

A diagnosis that is associated with a cluster of Actual or High-Risk signs and symptoms that are predictive of certain circumstances or events. 1. Rape-Trauma Syndrome 2. Disuse Syndrome 3. Posttrauma Syndrome 4. Relocation Stress Syndrome 5. Impaired Environmental Interpretation Syndrome

Medical Diagnosis

A statement of the patient's alterations in structure and function, and this results in the diagnosis of a disease or disorder that impairs normal physiologic function. - Tends to remain unchanged throughout the illness.

Actual Diagnosis

Based on human responses to health conditions and life processes that exist in an individual, a family, or a community. - Supported by defining characteristics (signs/symptoms)

Assessment

Collecting a comprehensive information base about the patient from the: - Physical Examination - Nursing History - Medication History - Diagnostic Test Results - Professional Observations. Problem/Risk-Identifying phase ( First phase of nursing process) - Admission --> Discharge

Nursing Order

Describes how specific actions, including time intervals, will be implemented for an individual patient.

Drug Monograph

Detailed explanations of the purpose for which a drug is intended, and assist the nurse to identify common and adverse effects and drug interactions for patient monitoring.

Interdependent Actions

Implemented actions with the cooperation of other members of the healthcare team.

Primary Source

Information directly from patient.

Tertiary Sources

Information gathered from literature to provide depiction of characteristics of disease, nursing interventions, diagnostic tests used, pharmacologic treatment prescribed, dietary interventions, physical therapy undertaken, and other factors pertinent to the patient's care requirements.

Secondary Sources

Information gathered from relatives, significant others, medical records, lab reports, nurses' notes, etc..

Core Measures

Measures of care that are tracked to show how often hospitals and healthcare providers use the care recommendations identified by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia or for patients who are undergoing surgery.

Independent Actions

Nursing actions that are not prescribed by a healthcare provider that a nurse can provide by virtue of the education/licensure attained.

Dependent Actions

Performed actions by the nurse on the basis of the healthcare provider's orders. - The administration of prescribed medications and treatments.

Critical Pathways

Standardized, automated care plans that integrate standards, interventions, goals and outcomes into the patients electronic medical record. - Multidisciplinary plan that is used by all caregivers to track the patient's progress toward expected outcomes within a specified period.

Measurable Goal Statement

Starts with an action word that is followed by the behavior or behaviors to be performed by the patient or the patient's family within a specific amount of time. - All goal and outcome statements must be individualized and based on patient's abilities.

Nursing Actions

Suggested by the etiology of the problems identified in the nursing diagnosis and that are used to implement plans. - May include activities such as counseling, teaching, providing comfort measures, coordinating, referring, using communication skills, and performing the actions listed in a health care provider's orders

Evidence-Based Practice

The application of data from scientific research to make clinical decisions about the care of individual patients. - Implementing best care practices evolved from scientific studies to improve patient outcomes.

Planning

The process of developing a plan to meet the patient's needs. 4 Phases: 1. Priority setting. (identify problems and prioritize depending on patient needs) 2. Development of measurable goal and outcome statements. (Short/long-term goals to be followed when providing care) 3. Formulating nursing interventions. (plan which intervention to use based on anticipated patient behavior) 4. Formulating anticipated therapeutic outcomes that can be used to evaluate the patient's status. (Third phase of nursing process)

Actual Nursing Diagnosis Statement

Three-part Statement: 1. Patient problem summarizing the issue. 2. Contributing factors or cause 3. Defining Characteristics

Risk/High-Risk Diagnosis Statement

Two-part Statement: 1. Diagnostic label from the NANDA-I approved list. 2. Risk Factors that make the individual or group more susceptible to the development of the problem.