Implementation/fulfillment of a prescribers prescribed course of treatment or plan.
Compliance
Acknowledges acceptance of patient/family participation in the nursing process
Any preventable adverse drug event involving inappropriate medication use by a
Medication Error
patient or health care professional; it may or may not cause the patient harm
An informed decision on the part of the patient not to adhere to or follow a
Noncompliance
therapeutic plan or suggestion
An organizational framework for the practice of nursing. It is a well-established,
Nursing process
research-supported framework for professional nursing practice
Descriptions of specific patient behaviors or responses that demonstrate meeting of
Outcomes or achievement of behaviors related to each patient's human needs. These
statements are specific while framed in behavioral terms and are measurable
Any health care professional licensed by the appropriate regulatory board to
Prescriber
prescribe medications
Assessment
Diagnosis
Outcome ID & Planning
Implementation
Five phases of the nursing process
Evaluation
assessment, human need statements, planning with outcome identification,
implementation including patient education, and evaluation
Assessment
Getting information from many sources- data collection (medical history, physical
assessment, and environment)
Step 1 of the nursing process
in terms of pharmacology- what did the doctor/prescriber order, what are we giving
the patient(prescription/medication order)
- The patient's full name
- Date of the order
- Drug dose amount
- Name of the drug preceded by the abbreviation Rx
- Dosage
Medication order components
- Route of administration (Mouth, IV, subcutaneous)
- Time and frequency
- Prescriber's signature (without which the medication order is not legal)
- Number of refills
- Quantity
What is data from the assessment NP objective and subjective data
portion categorized as
information that is seen, heard, felt, or smelled by an observer (five senses)
Objective data
signs
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symptoms
Subjective data all spoken information shared by the patient, such as complaints, problems, or stated
needs
Once the assessment phase has been completed, the nurse analyzes objective and
Human needs statements subjective data about the patient and the drug and formulates statements of human
need fulfillment/alteration
Diagnosis/human needs statement
This is the step after you have gathered information on the patient. Identification of
human needs is the result of clinical judgment about human response to health
conditions and/or life processes, critical thinking, creativity, and accurate collection
Step 2 of the nursing process
of data regarding the patient and the drug.
Human need statements associated with drug therapy develop out of data
associated with various disturbances, deficits, excesses, impairments in bodily
functions, and/or other problems or concerns related to drug therapy.
the identification of a disease or condition by a doctor/what doctor says is wrong
Medical diagnosis
with you after running tests/x-rays
a health problem that can be treated by nursing measures
Nursing diagnosis problem/sign or symptoms. that is caused by medical diagnosis ex. chest
pains(nursing diagnosis) doctor orders an x-ray and says you have pneumonia
(medical diagnosis)
Explain why you are giving medication, instruct the patient when to take it, and if
Knowledge deficit
insurance covers it or not
Risk for injury
Outcome identification + planning
The changes you expect to see after data is collected and human needs statements
are formulated. This is where the planning phase begins and outcomes are identified.
Step 3 of the nursing process
outcomes should be;
measurable
realistic
objective with an established time frame for their achievement
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