NURSING PROCESS

Data are categorized into 2:

IN PHARMACOLOGY  Objective data
 Subjective data
Nursing Process
- A decision-making problem-solving Objective data
process to provide efficient and - Any information gathered through
effective care the senses or which is seen, heard,
- The application of nursing process felt, or smelled
would drag therapy ensures that the - May also be obtained from:
patient receives the best, safest,  Physical assessment
most efficient scientifically base  Nursing history
holistic care  Past and present medical
history
Assessment  Laboratory tests
- Is an information – gathering phase  Diagnostic studies or
to complete a database of procedures
information about a patient  Measurement of vital signs,
-Includes: weight, and height;
 History medication profile
 Physical exam
 Lab results
 Diagnostic tests Medication Profile
Allergies - This include but are not limited into
Current medications the following information
Why patient is taking drugs - Any and all drug use; use of home or
Condition of patient’s skin folk remedies and herbal and/or
Used of tobacco homeopathic treatments, plant or
Alcohol animal extracts, and dietary
Coffe supplements
Caffeine- containing beverages - Intake of alcohol, tobacco and
caffeine; current or past history of
 Medical problems illegal drug us; use of over-the-
 Language and literary skills counter (otc) medications, use of
hormonal drugs, past and present
health history and associated drug
Methods of Data Collection regimen(s)
Includes:
- Interviewing
- Direct and indirect questioning
- Observation
- Medical records review
- Head to toe physical exam
- Nursing assessment
Subjective data
- This includes all spoken information
shared by the patient
- Such as:
 Complains
 Problems
 Stated needs: like dizziness,
headache, vomiting and
feeling hot for 10 days
Assessment
a. Past History-past medication or
illnesses which can influence the
drug to be taken, the drug use or
use of other drugs that is prescribe
by the doctor
- Any allergen that can provoke the
action or provide a caution of a drug,
food, and animal product
- Level of education- the level of
understanding of the disease and
therapy, social support, financial
support, and pattern of health care
b. Physical Assessment –this talk about
the weight, age, physical parameters
related to disease or drug effects.
Problem Identification and Diagnosis
- Simple a statement of the patient’s
status from a nursing perspective
- This focuses on identification of a
patient’s actual and potential health
problems
3 Key Elements in Problem Identification
1. The Problem (P)
2. Etiology (E)
3. Signs and Symptoms (S)
Such as: non-compliant related to inability
to accept diagnosis and treatment regimen
as evidence by not taking the medication as
ordered
Example: Anxiety related to hair loss,
secondary to chemo therapy as evidence by
restlessness, facial tension, and insomnia
Planning
- This includes effective planning for
responsible delivery of nursing care
which includes: Care related goals
and objective base diagnosis
- Which taken to consideration:
 Physical
 Psychological
 Socio-cultural
Drug regimen- is the systematic plan for
drug therapy which states:
1. What drug has been ordered
2. When they are to be given
3. Route of administration to be use
Major Purpose of planning
-Prioritize the nursing diagnoses and specify
goals and outcome criteria, including the
time frame for their achievement
Planning Phase
-Provides time to obtain special equipment
for interventions, review the possible
procedures or techniques to be use and
gather information from oneself (the nurse
or for the patient)
-This will lead to the provision of safe care if
professional judgement is combined with
the acquisition of knowledge about the
patient and the medications to be given
Implementation
- Actual nursing interventions used to
meet the expected outcomes
- They are identifies during the
planning phase and result in the set
of instructions
 Proper drug administration:
the nurse must consider the
 rights to ensure safe and
effective drug administration
 Comfort measures: the
patient is more likely to be
compliant with the drug
regimen if the effects of
taking drugs are not too
uncomfortable
 Placebo effect: the
anticipation that a drug will
be helpful has proved to
have tremendous impact on
the actual success of drug
therapy
 Patient and family education:
the patients become more
responsible to their own
care, they should have all the
information necessary to
ensure safe and effective
drug therapy
Implementation phase- the nurse
intervenes on behalf of the patient to
address specific patient problem in need
-this is done through independent nursing
actions, collaborative activity such as:
~physical therapy
~occupational therapy; and
~music therapy
And the implementation of medical orders
The family, the significant others and care
givers assist in carrying out phase of the
nursing care plan
Specific interventions that relate to
particular drugs like:
- Giving a particular cardiac drug only
after monitoring patient pulse and
blood pressure
- We can also do the non-
pharmacologic interventions that
enhance the therapeutic effects or
medications in patients education
are major components of the
implementation phase
7 Rights of Safe Medication
1. Right Medication- this means that
the medication that is given is the
right medication
-Errors in this right are made
or done when the pharmacy
incorrectly dispenses a
medication, similar to the
ordered medication
-The nurse administers a
medication that has a similar
name the nurse administers
the medication not repaired
by them, that’s why when
you are the medication nurse
the rule in the ward I that
you have what you repaired
-Errors can be made when
the nurse incorrectly
identifies the medication
2. Right Patient- giving the medication
to patient for whom it was intended
-For us to avoid errors we
need to use 2 identifiers:
 State name
 Name band
-With the medication
administration record
-Computerize charts in the room will allow
the nurse to scan the arm band
-In long term care facilities pictures are
sometimes use
3. Right Dosage- this means that the
patient is given the dose that was
ordered and a dose that is
appropriate for the patient
-We can commit errors for this right if the
dose is inappropriate which can be avoided
if the pharmacist and the nurse are aware W’s in Documentation
of the usual dosage of the medication. - When documentation
-In order to prevent that, we need to administration on the patients chart
double check with the physician whenever
there is a question about the dose 1. When(time)
-Be sure that the drug in calculation are 2. Why (includes):
done correctly and double check.  Assessment
 Symptoms
 Complains
4. Right Route- the medication is given  Values
only the route that was ordered and 3. What (like):
that the route is safe and  What is he medication
appropriate for the patient.  What is the dose
-We should know the usual route for the  What is the route
medication for drugs to be given 4. Where- the site
-Always double check route of 5. Was- the medication tolerated and if
administration. known is it helpful/was it helpful to
the patient

5. Right Time- the drug was given at Evaluation

the correct time as ordered or
according to agency policy
-Most institutions consider a medication to
be given on time if given 30 mins before or
after the prescribe time
-We have watched medication that cannot
be given with food so they are given before
meal and medications that must be given
with a meal need to be given with meals
6. Right Reasons- this is very important
to make sure the right medication
was ordered
7. Right Documentation- the nurse
needs to document the delivery of
the medication soon after it is given
so medications are not given again
-Be sure to follow the agency policy on the
documentation
- Part of continuing process of
patient’s care that leads to changes
in assessment, diagnosis, planning
and intervention
- The patient is usually evaluated
continually for therapeutic response
and the occurrence of any adverse
drug effects: -Drug to drug
-Drug to food
-Drug to alternative
therapy
-Drug to laboratory
test interactions
- Some drug therapy requires
evaluation on specific therapeutic
levels, so with regards to evaluation
this determines if our goals have
been met satisfactory
- It should be done not only at the
end of the process but should go on
from the start
- It is done continually

Questions that can be use in Evaluation:

a. Does the patient exhibit signs that
medication is effective?
b. Are there any secondary effects?
c. Are there drug interactions that may
lead to toxicity?
d. Is the patient taking medication as
ordered?