the process that helps you gather information about the patient. involves looking and listening carefully --- 9begin from moment you walk into the room)
Ausculation
listening with the stethoscope
Database
Record from which all other nursing prosesses grow (begins to build during the Assesment process)
Subjective data
information given by patients or family, includes the concerns or symptoms felt by the patient
EX. chief problem (in pt.'s words
Objective Data
Provided when the health care provider given the patient a physical examination. - also comes from documents
Inspection
Close observation
Palpation
feeling
percussion
deteceing differences in in vibrations through skin
Nursing process
and five steps
the well known plan that helps guide the nurses work
1 - Assessment
2 - Diagnosis
3 - Planning
4 - implamentation
5 - Evaluation
Diagnosis
a conclusion about the patient's problem
the SIX patients rights
1 - the right drug
2 - the right time
3 - the right dose
4 - the right patient
5 - the roght rout
6 - the right documentation
Implamentation
involves following a care plan, and giving medicine acuraelty to a patient
the right drug
carefully check the spelling of the name and the dose of each medication before the drug is given.
- read the drug label at least three times
1 before taking the drug from the unit dose cart
2 before preparing, and measuring the prescribed drug
3 before putting medications back in the shelf or before opening the medication to give to the patient
Evaluation
the process of looking at what happens when a care plan is implamented
therapeutic effects
are seen when the drug dose does what it was supposed to do.
Adverse side effects
seen when patients do not respond to their mediationsin the way that they should or develop mew signs or symptonms.