once assessment of the patient and the drug has been completed, the specific prescription of medication order from any prescriber must be checked for the following six elements:
1. patients name
2. date the drug order was written
3. name of drugs
4. drug dosage amount and frequency
5. route of administration
6. prescribers signiture
nursing diagnoses are developed by professional nruses and are used as a means of communicating and sharing information about the patient and the patient experience.
Formulation of the nursing diagnoses is usually a three step process with nursing diagnoses stated as follows: part one of the statement is thehuman response of the patient to the illness, injury or significant change. this response can be an actual problem, and increased risk of developing a problem, or an opportunity or intent to improve the patients health. part two of the nursing diagnosis statement identifies factors related to the response, with more than one factor often named. the nursing diagnosis statement does not necessarily claim a cause and effect link between these factors and the response; it indicates only that there is a connection between them. part three of the nursing diagnosis statement contains a listing of clues cues evidence or other data that suppose the nursesclaim that the diagnosis is accurate
tips for writing nursing diagnoses include the following....
1. start with a statement of a human response
2. connect the first part of the statementor the human response with the second part, the cause, using the phrase "related to"
3. be sure tha the first two parts are not restatements of one another
4. when appropriate, include several factors in the second part of the statement such as associated factors
5.select a cause for the second part of the statement that can be changed by nursing interventions
6. avoid negative wording or language
7. finally, list clues or cuews that led to the nursing diagnosis in the third part of the statement, which may also include more defining characteristics (as evidenced by)
Six rights of medicataion administration
other information that should be documented
1. if a drug is not administered and why with actions taken by the nurse
2. refusal of a medication with information about the reason for refusal, if possible, if a medication is refused and the cause of refusla identified, the nursing care plan should be revised and further actions implemented.
3. actual time of drug administration
4. data regarding clinical obsercations and treatment of the patient if a medication error has occured. if there is a med error, documentation of completion of an incident report should not be included in the nurses notes. however, an incident report should be completed with the entire event, surrounding circumstances, therapeutic response, adverse effects, and notification of the prescriber described in detail
drug interactions in which the effect of a combination of two or more drugs with similar actions is equilivant to the sum of the individual effects of the same drugs given alone. for example 1+1=2
adverse drug event
any undesirable occurrence related to administering or failing to administer a prescribed medication
adverse drug reaction
any unexpected, unintended, undesired, or excessive response to a med given at theraputic dosages (as opposed to overdose)
a general term for any undesirable effecrs that are a direct response to one or more drugs
a drug that binds to and stimulates the activity of one or more receptors in the body
an immunologic hypersensitivity reaction resulting from the unusual sensitivity of a patient to a particular medication; a type of adverse effect
a drug that binds to and inhibits the activity of one or more receptorsin the body. antagonists are also called inhibitors