NURSING PROCESS AND PHARMACOLOGY A PLAN TO ORGANIZE THE NURSES ACTIVITIES

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

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

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

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

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

EVALUATION Ongoing Independent of time frame established