1. NURSING PROCESS AND PHARMACOLOGY
A PLAN TO ORGANIZE THE NURSES ACTIVITIES

2. STEPS OF THE NURSING PROCESS
ASSESSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
Nursing is holistic.

3. ASSESSMENT DATA Subjective Objective
Supplied by the patient and family
Objective
Documentation and fact
Subjective
Current health history / family history
Client knowledge about medications dosage, expectations, perceptions, compliance with regime
Allergies and reactions include foods (latex and avacados and bananas
OTC use
Herbals
Street drugs.
Environment home situations ability to learn and follow directions, follow through of patient and family elderly and child proof caps
Dietary patterns
ADLs
Finances can they afford the meds
Objective
Vss, lab data, tests, physical assessment data
Inspection what you see,
Palpation what you feel,
Auscultation what you hear with the stethescope,
Percussion detecting sound differences produced by vibrations

4. DIAGNOSIS Nursing Diagnosis Based on assessment data NANDA
North American Nursing Diagnosis Association
Helps to facilitate planning
Based on assessment and conclusions
Common language
Consider:
What are the major problems
How critically ill is the patient
What types of procedures or meds will the patient require
What special concerns or cultural beliefs
What special knowledge or equipment isneeded
What is the patient’s level of understanding
Examples include:
Knowledge deficit about drug effects/action/side effects/ r/t language difficulties
Alterations in thought processes r/t inability to remember to take medications
Risk for injury r/t side effects of medication i.e. dizziness, drowsiness

5. PLANNING Goal setting Client –centered
Acceptable to both client and nurse
Realistic and measurable
Shared with other health care providers
Realistic deadlines
Prescriptive for evaluation
Clear expectations
Client will independently administer prescribed dose of insulin by the end of the forth session of instruction.
What does the client need to know about administration, action, side effects, sings to report to nurse

6. IMPLEMENTATION
Nursing actions needed to accomplish the established goals.
Client teaching
Include family
Provide written and oral instruction
Cultural Considerations

7. EVALUATION
Ongoing
Independent of time frame established