3Learning Objectives List the five steps of the nursing process Identify subjective and objective data
4Five Steps of the Nursing Process AssessmentDiagnosisPlanningImplementationEvaluationThe nursing process is the framework for professional practice.The nursing process is a scientific, standardized process that ensures quality patient care.The nursing process assists the nurse in meeting standards for care.The nursing process facilitates a nurse’s accountability for his/her practice.
6Responsibilities Dictated by licensure and experience RN: licensure and authority to carry out allsteps of the nursing processLPN/LVN: working under the supervision ofthe RN; assess, implement, and evaluatewith guidanceUnder what organization is a nurse licensed?What is the difference between state and constitutional regulations?Can state regulations differ from constitutional regulations?LPN/LVN responsibilities are continually changing, so it is vital to know what the nurse practice act for your region legally allows.
7AssessmentGathering information to develop a database, or record, from which all nursing process plans developRequires skill and expertise of the nurseDatabase assessments gather information in all areas.An admission history is a database assessment.A focused assessment is done to assess a specific problem area.Nurses must determine when to use focused assessments. For example: A patient complains of shortness of breath. The nurse recognizes the possibility exists of a pulmonary embolism and a comprehensive respiratory, cardiac, and circulatory assessment may be needed.
8Assessment (cont.) Two types of data: Subjective data: obtained through questioning; information that cannot be measuredObjective data: obtained through observation; information that is observed or could be verified by anotherWhat information would be subjective in nature?What information would be objective in nature?Is subjective information less important than objective information?What objective information can be gathered if a patient states he has severe pain?
9Sources of Information PatientFamilyMedical RecordsHistoryHealth Care ProvidersLab ReportsWhat sources are subjective in nature?What sources are objective in nature?The patient is the primary source of information.Are there any other sources of information you can think of?
10Sources of Information (cont.) Techniques used to obtain objective data:Inspection = close observationPalpation = feelingPercussion = detecting differences invibrations through the skinAuscultation = listening with a stethoscopeAs nurses advance in their practice, they learn to become more proficient in assessment techniques.Nurses learn to systematically assess their patients.The patient is assessed prior to the equipment.Inspection and palpation are skills taught early in nursing programs. LPN’s/LVN’s learn to differentiate beginning level sounds upon auscultation.Percussion is typically taught in RN programs and more advanced nursing practice.
11Drug History Assessment Helpful information to be used in planning drug therapy:Symptoms, signs, or diseases that explain need for medicationCurrent (and sometimes past) use of medications and drugsProblems with drug therapyThe patient’s perception of the need for medication is essential in helping to plan his/her treatment.Many patients are unaware of why they are taking medications.An understanding of the patient’s current and concurrent disease processes is helpful.What questions could you ask to determine whether a patient understands the medications he or she is taking?
13Learning ObjectivesDiscuss how the nursing process is used in administering medications
14Diagnosis A conclusion about what the patient’s problems are. The physician makes a medical diagnosis.The nurse makes a nursing diagnosis.Medical diagnosis requires the expertise of the physician or qualified health care provider.A physician can diagnose cancer; however, it is not within the scope of LPN/LVN practice to diagnose disease.Nurses can diagnose human response patterns that may be related to the disease process.NANDA, or the North American Nursing Diagnostic Association, has identified a list of nursing diagnoses that the nurse can make.Dysfunctional grieving is an example of one of these diagnoses.
15Diagnosis (cont.) To make a nursing diagnosis ask: What are the major problems for the patient?What procedures or medications will the patient require?What special knowledge or equipment is required to give these medications?What special concerns or cultural beliefs does the patient have?What does the patient understand?Nursing diagnoses must be treatable by the nurse.Nursing diagnoses address the practice of the nurse as legally permitted by the nurse practice act of a given state/region.Nursing diagnoses should be written in a clear, concise, and modifiable manner, because they help determine what interventions would be helpful to treat the identified human response.The LPN/LVN is able to collect baseline data that assists the RN in making a nursing diagnosis.
16Diagnosis (cont.)Once the nursing diagnosis is made, a plan of care is initiated that includes patient and nurse involvement.Goals are established.Goals, or outcomes, are mutually established with the patient.If the patient is unable to participate in the development of the care plan, the nurse establishes a plan of care that is in the patient’s best interests.Nurses are patient “advocates.” They treat the patient in the manner they believe the patient would desire to be treated.
17Planning Patient goals Nursing goals Help the patient learn about a medication and how to use it properly.Nursing goalsHelp the nurse plan what equipment or procedures are needed to administer a medication.Patient goals are the outcomes the care plan has been developed to meet.There are short-term and long-term patient goals.Patient goals are identified in the care plan.Nursing goals are not part of the care plan. Nursing goals are verbally communicated between nurses.
18Four Steps of PlanningDetermine the reason for each medication to be given.Learn information regarding the medication.Plan for special storage, techniques, or equipment.Develop a patient teaching plan.The nurse must understand a variety of factors to safely administer a medication.What should a nurse do if he/she does not understand why a medication is given?What resources can the nurse use to get medication information?What types of medications are you aware of that have to be refrigerated?What questions can you ask to determine what information a patient already has before initiating a teaching plan?
19Four Steps of Planning (cont.) Prior to medication administration,critical thinking is essential to:Verify the accuracy of the medication by checking the medication record against the physician’s original order.Determine whether the type of medication and dosage are appropriate for the patient.What action(s) should a nurse take when an order is unclear?What action(s) should a nurse take when questioning a medication dosage?Can a nurse refuse to administer a medication?
20Planning If the nurse determines: the medication order is unclear or appears incorrectthe patient’s condition would decline with the medicationthe physician did not have all the relevant information needed before writing the orderthere is a change in patient conditionThe medication is HELD until the order isclarified.Under what circumstances would a nurse “hold” a medication?What actions could assist the nurse in clarifying an order?When a nurse “holds” a medication, accurate documentation and follow-up with the physician is essential.
22Learning ObjectivesList specific nursing activities related to assessing, diagnosing, planning, implementing, and evaluating the patient's response to medications
23Implementation Six Rights of Medication Administration 1. Right drug 2. Right time3. Right dose4. Right patient5. Right route6. Right documentationThere are no shortcuts when administering medications safely.If a medication isn’t documented, it is assumed to have not been given.Many facilities are instituting systems (ex., PYXis, BCMA) that automatically document medications have been given when they are removed from medication storage.Computerized equipment does not negate the importance of nursing input or scrutiny.
24Right Drug Drug label is verified three times 1. Before taking the drug from the unit dose cart or shelf2. Before preparing the prescribed dose3. Before replacing the medication on the shelf or before administering it to the patientInaccuracy in patient identification is the main reason for medication errors.Various identification methods are being instituted in facilities to avoid patient identification errors. These include hand-held scanners, ID pictures, and checking a variety of data on the ID band.If your nursing instructor hands you a medication to give, do you need to recheck it?
25Right Time Considerations: Action of the medication Hospital policies Patient routinesMedications are given when there is the best chance of absorption and the least risk of side effects.Medications interfered with by food are given 1 hour before or 3 hours after meals.Medications that cause nausea or drowsiness are often given at bedtime.Many medications are given on a strict schedule. These include hormones, antiparkinsonian medications, and cardiac medications.
26Right Dose Considerations: Age Weight Health status Recent changes in health statusNurses must be familiar with hospital policies regarding preparation of medications.Many institutions have a “double check” policy that requires one nurse to recheck a medication another nurse has drawn up.Insulin, anticoagulants, or critical care medications are often double-checked.Would you feel comfortable telling another nurse you did not agree with the amount of medication drawn up?As one ages, there is increased difficulty with vision at close range. A nurse may not recognize the diminished visual acuity.
27Right PatientIt is critical to identify patients using objective data such as ID number, name, date of birth.Many patients are at risk for misidentification; for example, those unable to effectively communicate with the nurse (pediatric, geriatric, critically ill, confused, non-English speaking patients).What other patients are at risk for misidentification?If you were in an accident, how would health care providers know who you were?What should a nurse do if he or she accidentally gave medication to the wrong patient?Do you think all nurses report their errors?
28Right Route Routes alter effects of medications. Nurses must not alter the route prescribed for a medication without a physician’s order.Most medications are given by the enteral (gastrointestinal route).The enteral route is the most unreliable route for medication absorption, because the gastrointestinal tract is highly variable in individuals.Acidity, food contents, ulcers, disease processes, and other variables alter absorption in the gastrointestinal system.Emergency medications are routinely given via the intravenous route to facilitate rapid absorption and avoid the “first-pass effect” of the liver.
29Right Documentation If it isn’t documented, it wasn’t given. Nurses should only document what they have given.Document accurately after the medication is administered.Nurses should not document a medication until it is administered.Medications should be documented in a timely manner to avoid errors.Patients have the right to refuse medication.The nurse must document the refusal and communicate this to the physician.You administer a PRN pain medication to another nurse’s patient while she is on break. When the nurse returns to the floor, she tells you she had already given that patient medication within the last hour but forgot to document it. Who is accountable for this error? You or the other nurse?
30Evaluation Have therapeutic effects from the medication been seen? Have any side effects from the medication been seen?Have any allergic responses from the medication been seen?It is important for patients to understand the time frame in which the therapeutic effects of a medication will occur. Teaching is essential, because patients may stop taking prescribed medications once they start to feel better.Side effects such as slight nausea are not considered allergic effects.Allergic effects may include rash, severe nausea and vomiting, difficulty breathing, and drop in blood pressure.The health care provider must determine whether a medication is causing side effects or allergic responses.