Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide Planning When appropriate nursing diagnoses have been identified, the nurse and patient must establish goals for each diagnosis and interventions to move the patient toward the expected outcomes. Goals or expected outcomes for medication safety might include: • The patient describes the purpose, action, and expected effects of each medication. • The patient states when each medication should be taken and the dose that should be taken. • The patient demonstrates proper administration of each medication. • The patient describes any unexpected effects that might occur with each medication and describes the appropriate steps to take if an undesired effect occurs. Intervention/Implementation Interventions that might be used will depend on the goals set, the patient's readiness to learn and perform the skills, and the patient's physical and mental conditions. Specific interventions for medication safety management might include: • Teaching related to each medication, including the name, dose, route, schedule, expected effects, and any adverse effects that might occur. • Describe what steps must be taken, if adverse effects occur. • Monitor vital signs. • Demonstrate the delivery of each medication, particularly if the medication is to be given in any manner other than orally. • Ensure that the patient has the appropriate equipment for the medication administration at home. • Educate the patient and family about the five rights of the medication administration. Evaluation Evaluation should include an assessment of the patient's progress towards the expected outcomes. The evaluation should include: • Assessment and documentation of the patient's response to each medication. • Assessment and documentation of any undesired or unexpected effects. Any of these effects should also be reported to the prescribing provider. • Assessment and documentation of the patient's response to teaching. • Assessment of the patient's adherence to the medication regimen. • Revision of the patient's plan of care should be based on the response to interventions and progress toward the goals.

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