Nursing Process Flashcards
Nursing Process
Assessment
Diagnosis
Plan and outcome
Implementation
Evaluation
Nursing roles in medication administration
Safety
Interpret doctors orders
Prepare exact dose of drug
Correctly identify patient
Administer proper dose by prescribed route and time interval
Document administration of drug
Monitor patient response for therapeutic reaction and any adverse effects
Six rights of safe medication administration
Right patient
Right medication
Right dose
Right route
Right time
Right documentation
Medication orders (prescriptions)
Verbal orders
Legal order is required
Can be a verbal order (prescriber to nurse)
By telephone
Error phone
Emergent situation by staff request
Make sure when you write it, you always READ it back and receive CONFIRMATION
Prescriber signature required within 24 hrs after verbal order
Seven ESSENTIAL Components to get when taking a medication order (prescription) from a prescriber
Patients full name and DOB and/or MR#
Date and time written
Name of medication
Dosage
Route
Time and frequency
Signature of prescriber or computerized signature
Special considerations to note when taking drug orders
Medication name
-trade name
-generic name
-pay attention to similar drug names or sound similar drug names. Do not assume
What does PRN mean
As needed
Prescriber orders will state “give when temperature is equal or greater to 102.5 F”
Must have an indication when to give the medication as needed
Methods of verbal delivery from prescriber
Verbal(in person)
Written
Electronic
Telephone (verbal order)
Computerized prescriber order entry (CPOE)
Order of how to write medication order from prescriber
Name of medication
Dosage
Route
Time/frequency
Order prescription types
Standing orders - administered until the dosage is changed or another medication is prescribed
PRN- as needed
Single one time use - given only one time
STAT - given immediate in emergency
Now - medication needed right away but not STAT
Prescriptions- discharge medication when going home
verify the order given with the patient
Get clarity of the order (so patient knows the drug they are taking)
Know the safety of the drugs (educate on the safety)
Known allergies
Type of drug
Therapeutic intent
Usual dose
Patient tolerance to the drug form
What are the three checks EVERY TIME
Order check - make sure the medication administration record matches the prescribers order
Med check - before medication gets dispensed check the medication administration record again before putting it into the container and check the EXPIRATION Date
Bedside check - at the patients bedside, double check the medication AGAIN along with the Medication Administration record before giving it to the patient
3 checks to prevent any medication errors
Additional patient rights
Right reason
Right evaluation
Right storage
Right education
Right to refuse the medication
Always document the patients refusal prior to notifying prescriber
Always be aware of state laws, polices and procedures regarding a patients rights when they refuse medication
Things to verify for the Right patient
Ask patient to state his/her name and DOB
Perform 2 checks with patient verbalization to the ID Band and to the MAR
(Name and DOB)
2 checks with ID bands and MAR
Medical record number, any known allergies and response to drugs or allergies
How to verify the Right Medication
Generic vs trade name
Always verify medication three times before administering the drug
Verify while you prepare the medication
Verify again after gathering the correct dose
And double verify right before you give it to the patient
