Nursing Process in Medication Administration

• The nursing process is the foundation for the clinical practice of nursing.
• The nursing process includes assessment, nursing diagnosis, planning, nursing intervention/implementation, and evaluation/recording therapeutic outcomes.

Assessment

• Assessment is the first step in the nursing process.
• It involves the comprehensive collection of data, including physical examination, nursing history, medication history, and professional observation.
• Assessment is an ongoing process, from admission to discharge.

Nursing Diagnosis

• A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems, according to NANDA-I.
• An actual nursing diagnosis includes a NANDA-I diagnostic label, contributing factors, and defining characteristics.
• Gordon's Functional Health Patterns Model can assist with nursing diagnosis.

Four Types of Nursing Diagnosis

• Actual diagnosis is based on human responses and supported by defining characteristics.
• Risk/high-risk diagnosis indicates the patient may be more susceptible to a particular problem.
• Health promotion and Wellness diagnosis has a one-part label.
• Syndrome diagnosis clusters signs and symptoms to predict certain circumstances or events.

Nursing Diagnosis vs. Medical Diagnosis

• Conditions described by nursing diagnoses can be accurately identified using nursing assessment methods.
• Nursing treatments/methods of risk-factor reduction can resolve conditions.
• Nurses are accountable for outcomes within their scope of practice.
• Nurses are responsible for research needed to clearly identify defining characteristics and causative factors.

Collaborative Problems

• Collaborative problems differ from nursing diagnoses when the intervention aims to prevent or treat a problem.
• The statement is worded with potential complications in the diagnosis.
• Evidence-based practice uses research to impact nursing practice changes, and interventions from research findings can be implemented into care plans.

Focused Assessment

• A focused assessment involves collecting additional data specific to a patient or family, validating a suggested problem or nursing diagnosis.
• Collaborative problems requiring prescriptive orders can be identified and differentiated from solutions that are within the nurse's scope of practice.

Phases of Planning

• Four phases of a nursing care plan are: setting priorities, developing measurable goal/outcome statements, formulating nursing interventions, and formulating anticipated therapeutic outcomes.
• Setting priorities involves identifying and prioritizing the most important problems based on patient needs.
• Developing measurable goal statements involves writing short- and long-term goals for the patient.
• Formulating nursing interventions involves planning interventions based on anticipated patient behavior.

Evidence-Based Practice

• Evidence-based practice applies data from scientific research to make clinical decisions about individual patient care.
• Aim is to improve patient outcomes with best practices evolved from scientific studies.
• Evidence–based practice utilizes best care practices to improve patient outcomes.

Priority Setting: Maslow's Hierarchy of Needs

• Physiological needs.
• Safety needs.
• Belonging needs.
• Self-esteem needs.
• Self-actualization needs.

Measurable Goal and Outcome Statements

• Begins with an action word followed by the behavior(s) to be performed by the patient or their family, within a specific time frame.
• All goal and outcome statements must be individualized and based on patient abilities.

Nursing Intervention or Implementation

• Actual process of carrying out the established plan of care.
• Dependent Actions: Performed by a nurse based on healthcare provider’s orders.
• Interdependent Actions: Implemented with the cooperation of a team.
• Independent Actions: Provided by a nurse by virtue of education and license.
• Nursing interventions meet physical needs, ensure patient safety, monitor for complications, and assess changes in patient's needs.
• Therapeutic outcomes evaluate the effectiveness of care.

Evaluating and Recording Therapeutic and Expected Outcomes

• All care is evaluated against nursing diagnoses (goal statements), nursing interventions and patient responses.
• The evaluation process involves the patient, family, and significant others who provide feedback and help determine goals.

Nursing Actions

• Dependent actions are performed based on healthcare provider's orders.
• Interdependent actions are implemented cooperatively with the healthcare team.
• Independent actions aren't prescribed by a healthcare provider, but can be provided due to education and licensure.

Anticipated Therapeutic and Expected Outcome Statements

• These statements document the effectiveness of the care delivered.
• Therapeutic outcomes can identify the outcomes anticipated from the use of drugs listed in a particular classification.

Evaluation

• Evaluation is the final phase of the five-step nursing process.
• Nurse determines whether the expected outcomes were met.
• Evaluation recognizes the completion of goals.
• Evaluation facilitates new data input regarding the development of additional problems or lack of therapeutic responsiveness.

Assessment in Pharmacology

• Reasons for a drug history: evaluate medication need, obtain current and past use of over-the-counter medication, and identify drug therapy problems.
• Relies on primary, secondary, and tertiary sources.
• Primary source comes from the patient.
• Secondary sources include relatives, significant others, medical records, and lab reports.
• Tertiary sources include literature, diagnostic tests, and diet information.

Nursing Diagnosis and Pharmacology

• Nursing diagnoses often are formulated based on drug therapy.
• Most commonly associated with drug treatment for a disease or adverse effects from drug therapy.
• Nursing diagnoses also can originate from pathophysiology caused by drug interactions.
• Reviewing drug monographs helps identify problems related to medication therapy.

Planning in Pharmacology

• Identify therapeutic intent and common/serious adverse effects.
• Confirm recommended dosage and route of medication.
• Ensure the schedule of medicine administration aligns with provider's orders.
• Teaching patients to keep response records, learn techniques of self-administration, and understand proper storage and refilling.

Nursing Intervention or Implementation in Pharmacology

• Involves dependent, interdependent, & independent nursing actions.
• Nurses prepare prescribed medications with procedures ensuring patient safety:
  • Selecting correct supplies (e.g., syringes).
  • Verifying aspects before preparation.
  • Collecting data for baseline assessments.
  • Administer medication by correct route.
  • Document all administration aspects.
  • Implementing actions to minimize expected side effects.
  • Educating patient as appropriate.

Evaluating Therapeutic Outcomes in Pharmacology

• Includes assessing patient responses to medications.
• Determining signs/symptoms of recurring illness.
• Assessing adverse effects.
• Determining patient's ability to receive education and self-administer medication, plus potential for compliance.

Explore the nursing process in medication administration, from assessment to evaluation. Understand how to prioritize actions for side effects and plan pharmacological interventions. Learn to differentiate between actual and risk nursing diagnoses for patient-centered care.