Beruflich Dokumente
Kultur Dokumente
Assessment of Client
Collect Subjective & Objective data: Client, Drug & Environment Use current Drug handbook/text reference/ licensed pharmacist Complete a drug history Perform a Nursing Physical Assessment Create a medication profile
Consider clients experience with meds/health care system, previous hosp. Check vital signs (establish baseline) List meds client is taking /how taken/when List new meds ordered Use holistic framework- identify emotional, physical, cognitive, cultural & socioeconomic factors impacting drug therapy & nursing process
Check drugs adverse effects & contraindications, routes of administration, toxicity, therapeutic levels Drug action Are there any age specific developmental concerns How does the cultural origin & racial/ethnic group of client influence the drug therapy
Medication Orders
Orders must contain six elements: Clients name Date & time order was written Name of the medication Dosage (includes size, frequency & number of doses) Route of delivery Signature of prescriber
Base diagnosis on conclusion about risk factors, actual client needs or problems based on knowledge base. E.g. nursing diagnosis include: Deficient knowledge; risk for injury; noncompliance Diagnosis based on s/e or risk factors e.g.:. fatigue, constipation, impaired tissue perfusion, sexual dysfunction, sleep disturbance, urinary retention
Prioritize the nursing diagnosis Specify objective, measurable, realistic goals Establish a time period for achievement of outcomes If order is in question- do not give- call physician for clarification/further instructions. Document all information obtained!!
Implementation
Requires constant communication& collaboration with client& health care team Follow the six rights: Right drug Right dose Right time Right route Right client Right documentation
Right to a double check Right to proper storage/documentation Right to accurate calculation& preparation Right to careful checking of transcription of orders Client safety- use of correct administration procedures Right to accurate routes of administration
Right to close consideration of special situations e.g.: difficulty with swallowing, client with NG tube or who is unconscious Right to having all measures taken to prevent and report med errors if they occur Right to individualized /complete client teaching Right of accurate/cautious monitoring Right to accurate documentation
Monitor client responses to the drug Monitor expected and unexpected responses Monitor therapeutic (intended effects), side effects , adverse effects & toxic effects Document !! Very important!!