Week 2 Flashcards
Briefly list/identify and describe the 5 steps to the nursing process.
Diagnosis
Nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs
The diagnosis is the basis for the nurse’s care plan
Examples of nursing diagnosis
-Activity Intolerance
-Risk for Falls
-Impaired gas exchange
-Acute/Chronic Pain
-Impaired skin integrity
-Delayed growth and development
The Nursing Process: Planning
Goals & Outcome criteria
(SMART)
Objective, measurable, & realistic w/ an established time period
Implementation
Includes client education (HUGE!!!)
Initiation & completion of specific nursing actions as defined by the nursing diagnoses, goals, and outcome criteria
Can be independent, collaborative, or dependent upon a prescriber’s order
Examples of implementation
- RN will administer scheduled oral pain medication as ordered and assess client’s response to pain medication hourly
- RN will teach client relaxation and techniques to reduce abdominal pain
Evaluation
Both the client’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified PRN
*Accurate & timely documentation related to
*Goal met
*Goal partially met
*Goal not met
Clinical Judgement Measurement Model (CJMM)
Recognize cues
-Filtering information from different sources (e.g., signs, symptoms, medical history)
-What are some expected responses and behaviors??
Clinical Judgement Measurement Model (CJMM)
Analyzing cues
-Linking the recognized cues to the client’s clinical presentation and establishing probable client needs, concerns, or problems
-Expected responses and behaviors??
Clinical Judgement Measurement Model (CJMM)
Prioritize hypothesis
-Establish priorities of care based on the client’s health problems (e.g., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic test, lab values, etc.)
-Expected responses and behaviors???
Clinical Judgement Measurement Model (CJMM)
Generate solutions
-Identify expected outcomes and related nursing interventions to ensure clients’ needs are met
-Expected responses and behaviors??
Clinical Judgement Measurement Model (CJMM)
Take-Action(s)
-Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health
-Expected responses and behaviors??
Briefly list/identify and describe the 6 steps to the clinical judgement measurement model (CJMM).
Evaluate outcomes
-Evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met
-Expected responses and behaviors??
Discuss the 9 rights of medication administration.
1.Right Drug
2.Right Dose
3.Right Time
4.Right Route & Form
5.Right Client
6. Right Documentation
7. Right Reason/Indication
8. Right Response
9. Right to Refuse
Briefly describe a medication error.
Defined as any preventable event that may cause or lead to inappropriate medication use or patient harm
Discuss the “DO’S“of documentation
-Make sure you’re in the correct client chart
-Document only the facts
-Document client education
-Document client’s refusal of medication (alert HCP & CN)
-Record each and any phone call to the HCP with the exact time, message, and response
Discuss the “DONT’S“of documentation
-Document ahead of time
-If you had to fill out an incident report, don’t document that you did in the EHR
Discuss the influences of the patient’s age on the effects of drugs and drug responses.
As people grow older, there is a higher risk for toxicity and adverse effects.
Identify drug-related concerns during pregnancy and lactation and provide an explanation of the physiologic basis for these concerns.
Any medication taken has the potential to reach the developing fetus
Passive Diffusion via the placenta
lipid soluble
smaller molecular weight
unionized/non-polar etc
Lactation A vast number of drugs can enter breast/chest milk
Drug profiles that can easily cross:
-Lipid soluble
-Small molecular weight
-Non-ionized
Avoid long-acting drugs (XL, long half lives)
Typically give medications AFTER breastfeeding/ chest-feeding
1st trimester is generally the period of
Greatest risk
The last trimester involves the highest % of drug absorption by the fetus why?
(increased blood flow + a larger fetus!)
What are Teratogenic drugs?
Drugs that may cause birth defects
Category A: no risk
Category X: Fetal abnormalities
Summarize the impact of age-related physiologic changes on the pharmacokinetic and pharmacodynamics aspects of drug therapy.
What happens as we age?
total body water mass decrease
muscle mass decrease
body fat increases
Explain how these age-related changes in pharmacokinetics influence various drug effects and drug responses across the lifespan.
Geriatrics
ADME
Absorption:
Decreased gastric acid production + slower gastric emptying time
Distribution:
Decreased body water + mass, more fat content
Decreased protein binding
Metabolism
Declined liver function
Elimination
Declined kidney function
