123 unit 2

• Assesments
• Nursing Dx
• Planning 
• Implamenting 
• Evaluation

• Nursing process
• Guidline for clinical care

Term given to PT on whats goin on

• Interput and anylaze clustered data
• Identify PT problem and strengths
• Formulate nursing dx-statement of how pt is responding to actual problems 

• Nursing Dx within nursing practice 
• identfies pt responce to illness/problem
• can change from day to day
• Medical Dx within medical practice 
• Focus on curing illness
• Stays the same 

PES format-Problem-Etiology-S&S

Problem statement-pt responce to problem (NANDA)

Etiology-what causes/contributed to PT problem

etiology must cause problem

• Signs and symtoms-evidence of problem
• state "as evidence by" AEB

• Has all three parts PES
• ex: Imbalanced nutrition: less than body requires related chonic diarrhea, nasuea and pain.  As evidence by height 5'5" weight 105

• has just the PE part of PES
• ex: risk for falls related to altered gait, generalized weakness

Family coping: potential for growth related to unexpected birth of twins 

• Maslows order of priority
• organize care plan based on nursing dx
• nurse and pt formulate goals and out comes 
• Interventions or tx based on critical judgement-including action, frequency, quantity, method and person to preform them

• ALWAYS starts with "Pt will..."
• goal-broad statement-one per Dx
• outcome-measurable criteria to meet goal(timeframe)

• Specific
• Measurable
• Attainable
• Relavant
• Time bound

• Short term
• Long term
• Acute care
• Physiologic goal
• Cognative goal
• Psychomotor goal
• Affective goal

• The doin step, providing care, carrying out interventions
• ALWAYS teaching pt
• use verbs, monitor, teach, further asses, observe, administer
• must have time frame

• Must be evidence based with rationals 
• Be aware of errors/inappropriate orders
• RN are legally responsible for complications

Any independent action the nurse can initiate without direct supervision 

Dependent nusring action requiring MD orders

nursing actions performed jointy with other health care teams members

• determines the effectiveness of nursing care plan
• done throughout patient care 
• comparision of pt behavior and response 
• meets goal from step 3

Supports nursing dx, indicates clients condition, primary communication tool, legal protection, quality assurance, education, decision analysis

• Nurses are legaly obligated to keep clients information confidential
• HIPPA
• Pt has right to read chart

• Record is permanent
• Sign full name 
• Do not write error for mistake

• Every pt must have assessment 
• Physical, psychological, environmental, self-care, client education, discharge planning 

standards of care, set nursing documentation standards 

• Communication with whole care team
• records or chart
• reports
• consultations
• referrals

• Progress/Nurses note
• Flow sheets
• Graphics
• Nusring care plan

• Traditional-Source oriented
• Problem Oriented medical-SOAP,PIE,Focus DAR
• Charting by exception
• Flow sheets

• Progress Notes
•    SOAP-sub,obj,assess,plan
•    SOAPIE-sub.obj,asses,plan,intervention,eval
•    PIE-problem,intervention,evaluation
•    Focus Charting (DAR)-data,action,response

• Factual
• Accurate
• Complete
• Current
• Organized

• Source records-seperate section for each discipline
• Charting by exception CBE-focuses on documenting deviations
• Case management plan-incorporates a multidisiplinary approch to care 

• Accuracy
• Brevity
• Completeness

the study of chemical/drugs and their effects on living orgamisms 

• chemical effect with a specific effect
• alter physiological function of body, do not creat a new function

• use of grugs to prevent disease 
• preventative
• palliative
• restorative
• why a drug is prescribed
• "why is drug prescribed"

• drug movement
• absorption
• distibution
• biotransformation (metabloism)
• excretion
• "how does it move through body"

Absorption

Distribution

Metabolism

Kindey and Liver 

Excretion

The stuy of the mechanism od drug action on living tissue at the cellular lever

"what the drug does to the body"

• Current knowledge 
• refer to resources (pharmacy)
• ? any order that is unclear
• refuse to give drug if harmful
• perform asses. & correct technique
• monitor pt responcse 
• document effects
• educate pt and family

Blood pressure 

• Schedule 1: highest potential for abuse-heroin
•     ''          2: morphine dilaudin
•     "          3: vicodin meperidine
•     "          4: valium xanax
•     "          5: cough suppresent w/codeine

Presciption-must have written order for pt to recieve 

Over the counter-pt treats self no written order

• Written legibly 
• Pt name 
• drug name 
• dose 
• route 
• frequency
• date 
• signature

all need to be on scritp!!

• MOST first call doc
• and document 

administer until order is changed 

given only once 

Give when needed but not stat

give as needed or asked for 

give immediatly emergency

• Daily, b.i.d.-twice a day, t.i.d-three times a day 
• HS-hours of sleep

• Therapeutic-organized by disease it treats
• Pharmacologic-organized by their mechanism of action
• Controlled substance schedule
• Pregnancy schedule- A mom can have X mom cant have 

• pharmacologic
• non steroidal anti-inflammatory agents
• Advil, motrin, ibeprophine

• pharmacologic
• slows BP HR increases contraction of heart

pharmaceutical name given by US adopted name council

• copyright name 
• popular name suppied by manufacture

• Any allergies
• taking any other meds
• can you swallow 
• fluid restiriction
• religious influences 
• vital signs 
• lab values r u pregnant

• symptoms of a dose to high 
• Adverse drug event ADE

can potentiate or inhibit drug action

may delay absorption

what conditions are adversly affected by this drug

60-100

3.5-5.0

3.5-5.0

5000-10000

10-20

0.5-1.2

The liver 

• If it goes up w/out creatinine its dehydration
• If both go up its kidney issue

2.2 lb

30mL

5mL

Must be disntegrated

process where tablet goes into solution 

All drugs must be in sloution to cross biologic membranes 

• what the body does to drug 
• Movement of drug by kidney and liver
• Absorption
• Distibution
• Metabolism
• Excretion

• Plasma membrans
•     diffusion(lipid soluble)
•     active transport(proteint bound soluble molecule)
•    

the first pass through liver takes part of drug-mostly oral meds

Gut to ass-pill and supository

Any area outside gut-IV, topical

Liquids--powders--capsules--tablets--coated tablets--enteric coated

• Mouth 
•    Buccal--Sublingual-avoids first pass
• Oral
•    Stomach--first pass to liver-low pH
• Small Intest
•    Most importatn for absorption-high pH

• Gases or aerosols 
• Rapid absorption
• Local effects

• edidermis low on lipid and water so good for absorption
• local effects 

diskc or patch contains a day or week of meds-steady rate of absorption

• All pass first pass effect-100% of drug is absorbed by body
• Intravenous 
• Subcutaneous 
• Intramuscular
• Intradermal

Albumin--plasma protein produced by liver

if no binding then toxicity levels will rise

• Highly lipid solube
• Not all can cross BBB
• caffeine, nicotine, antidepressants
• Less effective in older people 

• Chemical structure of a drug broken down to another form
• Water soluble easily excreted by LIVER 

metabolize lipid soluble drugs in liver 

• Kidney
• drugs removed from body 

Excretion of bile and feces 

• How long it takes to metabolize half of the drug
• Concentration of drug in blood to drop below 50%

Pain reducer, pain killer 

Used to correct cardiac function

removes excess water from body

prevent vomiting 

• non-steroidal anti-inflammatory drugs
• aspirin

Laxative

fever reducers

cough medicine

how long it takes to get response from drug

time it takes to reach maximum response 

• how long it lasts 
• time a concentration is sufficient to maintain response 

• increases HR
• Highly specific-less side effects
• Less specific-more side effects

• produces a desired therapeutic effect when bound to the receptor
• has same effect as body would 

• Produce no receptor response 
• Blocks the reaction of receptor

Bind to enzyme and block their action on cells 

• no enzyme action
• drug gets into cell and causes cell death

blood taken after drug given and just before next dose 

lowest concentration of drug in blood

concentration between minimum and toxic level

higher amout of drug given to achieve maximum effectiveness dose quickly

intermittent doses given to maintain levels 

drug induced birth defects from drugs given to mom

two or more drugs given to egual same responce 

two or more drug combined to get response greater than either drug 

Diabetics less sensation in limbs 

• responsible for stimulus arousal
• monitors imcoming stimuli

CNS despessant

unrealistic perception, bewilldered, disoriented, difficulty concentrating, scattered attention ect,

• reduce stimuli
• establish routine of care 
• speak calmly

• isolation
• impaired ability to receive and send stimuli
• inability to cognitively process stimuli

• non-rapid eye movement
• has 4 stages 
• 75-80% of sleep 

• rapid eye movement 
• 20-25% of sleep
• dreaming

What ever the pt says is pain

• sudden onset 
• short duration
• can ID cause 

• gradual onset
• duration 3 month 
• dont know what causes it 

Cutaneous-superfical-stimuli of nerve fibers in skin

Somatic-deep-tendons, bone ligaments 

Visceral-arise from internal organs

Referred-pain in different part of body than actual trama

Psychogenic-pain from a mental event not physical

Neuropathic-damaged nervous system

sensation perceived when body limb is missing 

Pain highly resistant to relief

Perceived at the source ans extends to nearby tissue

Chronic pain in the absence of any indentifiable cause 

• Transduction-biochemical release excite nocioceptors
• Transmission-impulse travel along neurons to spinal cord
• Perception-stimulus recieved by thalamus
• Modulation-body releases pain blockers

relieve pain by brain and emotion

• Involuntary
• sympathetic response increased BP, HR

• Voluntary
• guarding, rubbing, moaning

anxeity, fear, fatigue

• A-ask about pain
• B-believe the pt
• C-choose pain control
• D-deliver intervention
• E-empower pt and fam

• S-sevarity 0-10
• L-location
• I-intensity
• D-duration
• A-what asserbates pain

acetaminophen, NSAID's ibuprofen

• narcotics
• morphine, codeine

drug developed to enhance opioids effects

• constipations
• reduced respiration
• orthostatic hypertension
• urine retention 
• vomiting