patient is taking as well as any allergies (Berry et al.

,
2016).

NURSING PROCESS

One of the most significant advances in nursing has During the assessment, the nurse collects a
been the development of the Nursing Process. The comprehensive information base about the patient
nursing process guides nursing decisions about from the physical examination, the nursing history,
drug administration to ensure the patient’s safety to the medication history, and professional
meet medical and legal standards. The five steps of observations. Formats commonly used for data
the nursing process are dynamic, flexible, and collection, organization, and analysis are the head-
interrelated (Berry et al., 2016). to-toe assessment, body systems assessment, and
Gordon’s Functional Health Patterns Model. The
They include: head-to-toe and body systems approaches focus on
• Assessment the patient’s physiological, spiritual, and
• Nursing Diagnosis developmental factors that affect the individual’s
• Planning needs.
• Implementation
• Evaluation Box 4-2 shows Gordon’s Functional Health Patterns
Model (Clayton, 2016).

ASSESSMENT

Assessment involves collecting data that are used

NANDA International defines the Nursing Diagnosis as a “clinical judgement about individual, family, or
community responses to actual or potential health problems or processes.” It goes on to say that “Nursing
diagnoses provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is
accountable” (Berry et al., 2016).

TYPES of NURSING DIAGNOSIS:

• Actual Nursing Diagnosis – Based on human responses to health conditions and life processes that
exist in an individual, a family, or a community; supported by defining characteristics (i.e., manifestations
or signs and symptoms) that cluster in patterns of related cues or inferences.
• Risk/High Risk Nursing Diagnosis – A clinical judgement that an individual, a family, or a community
is more susceptible to the problem than others in the same or a similar situation; supported by risk factors
that contribute to increased vulnerability; in some cases, when an individual is more likely to develop aa
particular problem, the term high risk for is added.
• Health Promotion and Wellness Nursing Diagnosis – a clinical judgement about an individual, a
group, or a community in transition from a specific level of wellness to a higher level of wellness.
• Syndrome Nursing Diagnosis – these nursing diagnoses cluster actual or high-risk signs and
symptoms that are predictive of certain circumstances or events; the causative or contributing factors for
the diagnosis are contained in the diagnostic label; the five currently approved syndrome diagnoses are
as follows:
1. Rape-trauma syndrome
2. Disuse syndrome
3. Post-trauma syndrome
4. Relocation stress syndrome
5. Impaired environmental interpretation syndrome
 PLANNING

After establishing a Nursing Diagnosis, we have to develop a written care plan. A written care plan serves as a
communication tool among health care team members that helps ensure continuity of care. The plan consists
of two parts: Patient Outcomes, or Expected Outcomes, which describe behaviors or results to be achieved
within a specific time nursing interventions needed to achieve those outcomes (Berry et al., 2016).

IMPLEMENTATION

The Implementation Phase is when you put your care plan into action. Implementation encompasses all nursing
interventions, including drug therapy, that are directed toward meeting the patient’s health care needs. While you
coordinate implementation, you also collaborate with the patient and the patient’s family and consult with other
caregivers. Implementation can involve a multidisciplinary approach, depending on the needs of the patient and
his family (Berry et al., 2016).

Drug Administration – a drug administration route influences the quantity given and the rate at which the drug is
absorbed and distributed. These variables affect the drug’s action and the patient’s response.

Medication Orders:

• Routine Orders – detailed order for a medication given on a routine or regularly scheduled basis such
as every morning at 10 AM.
• PRN Orders – a medication which is ordered to be given “when necessary” or “as needed” within a
designated number of hours.
• One Time Orders – some medications to be given only once and are ordered to be given at a specific
time and then discontinued.
• STAT Orders – these medicates need to be given immediately or NOW.
Medication Safety - This involves where and how the
medication is given to the patient. The
• Remember the Three Checks: medication may be given by rectum,
Checking the: through the skin, in the eyes, in the
o Name of the Person ears, into the lungs, or into the vagina.
o Strength and Dosage - If the patient has an NG tube, make
o Frequency against the: sure the medication fits down the tube
 Medical Order and crush it only if the pharmacist says
 MAR and it is okay to crush the medication.
 Medication Container 6. Right Documentation
• Verify any medication order and make sure - You need to do this documentation at
its complete. The order should include the the time it is being administered and
drug name, dosage, frequency and route of not any other time before or after that.
administration. - Use blue or black ink to make your
• Check the patient’s medical record for an notes and never use a pencil or white
allergy or contraindication to the prescribed out if you make an error.
medication. If an allergy or 7. Right Response
contraindications exist, don’t administer the - Make sure you document the
medication and notify the practitioner. response the patient has to the
• Prepare medications for one patient at a medication.
time. - For example, if the medication is a pain
• Educate patients about their medications. medication, you need to document the
degree to which the medication
The Seven Rights: alleviated the pain.
1. Right Individual
- Collecting medication for only one
individual at a time.
- If there is any doubt that you are giving
a medication to the wrong person,
don’t give the medication until you are
sure you are giving it to the correct
individual.
2. Right Medication
- This involves reading the med label on
the bottle, including the brand name of
the medication and the generic name
of the medication (if both are
available).
- Make use of the nursing supervisor so
that you are not the only one
questioning the right medication.
3. Right Dose
- Be aware of the strength of each
medication you are giving.
EVALUATION
- Ask the pharmacist or the nursing
supervisor any time your calculations The final step of the Nursing Process, is crucial to
indicate that you need to give three ore determine whether, after application of the nursing
more pills of the same medication at process, the client’s condition or well-being
the same time as this is when improves. The Nurse applies all that is known about
medication errors are most likely to a client and the client’s condition, as well as
occur. experience with previous clients, to evaluate
4. Right Time whether nursing care was effective. The nurse
- Some medications need to be given at conducts evaluation measures to determine if
the same time every day or at the expected outcomes are met, not the nursing
same time with relationship to the interventions.
patient’s mealtime.
- In general, you need to give the The expected outcomes are the standards against
medication within one-half hour of which the nurse judges if goals have been met and
when it is supposed to be given (before thus if care is successful. Providing health care in a
or after the correct time). timely, competent, and cost-effective manner is
5. Right Route complex and challenging. The evaluation process
will determine the effectiveness of care, make
necessary modifications, and to continuously ensure
favorable client outcomes (Evaluation, n.d.).