compliance - ANS Implementation or fulfillment of a prescribers treatment plan or therapeutic
plan by patient.
medication error - ANS Any preventable adverse drug event involving inappropriate medication
use by a patient or health care professional; it may or may not cause the patient harm.
Noncompliance - ANS An informed decision on the part of the patient not to adhere to or follow
a therapeutic plan or suggestion.
Nursing Process - ANS Assessment
Diagnosis
Planning
Implementation
Evaluation
Outcomes - ANS Descriptions of specific patient behaviors or responses that demonstrate
meeting of or achievement of behaviors related to each nursing diagnosis. These statements
are specific while framed in behavioral terms and are measurable.
Prescriber - ANS Any health care professional licensed by the appropriate regulatory board to
prescribe medications.
QSEN - ANS Quality and Safety Education for Nurses
KSA - ANS knowledge, skills, attitudes needed to to continually improve the quality and safety
of a patient within a healthcare system
6 major initiatives of QSEN - ANS Patient-centered care
Teamwork and collaboration
Evidence-based practice (EBP)
Quality improvement (QI)
Safety
Informatics
Nine Rights of Medication Administration - ANS 1) Right drug
2) Right dose
3) Right time
4) Right route/form
,5) Right patient
6) Right documentation
7) Right reason
8) Right response
9) Right of patient to refuse
Right drug - ANS Must be checked against the medication label or profile 3x b4 giving
Right Dose - ANS always check the dose and confirm that is appropriate for patient's age and
size
check prescribed dose against available drug stock and against normal drug range
recheck all math calculations
REMEMBER NO LEADING ZERO's - ANS 0.2 is allowed, but NEVER 2.0
Right Time - ANS Include in your 3 check the frequency of the ordered medication, the time
administered and the last time the med was given.
***For routine med orders the standard of care is within the half hour it was prescribed.
PNR - ANS as needed
analgesic - ANS pain reliever
Never use abbreviations - ANS It is crucial to patient safety to never use any abbreviations for
any component of the drug order
Right Route and Form - ANS Never assume the route of admission
Right Patient - ANS requires confirmation of a patient's identity with two forms of identification
before drug administration
Right Documentation - ANS requires the nurse to record immediately the appropriate
information about the drug administered
** DOCUMENT ONLY AFTER med was given
Right Reason - ANS Is it appropriate to give the med
Right response - ANS refers to the drug and it's desired response
, continually assess and evaluate the achievement of the desired response as well as any
undesired response
right to refuse - ANS clients have right but need to clarify reason and notify prescriber
When can you NEVER return a med - ANS When it has been unwrapped, or opened.
Medication errors - ANS any preventable event or activity that can cause inappropriate
medication use or patient harm
Case study on Page 7
1) What questions does the nurse need to ask during the assessment phase - ANS Use of
home or folk remedies
Intake of caffeine
Use of over-the-counter medications
Past and present health history, in addition to her anemia
Pertinent family history
Cultural differences/issues
Responses to medications taken in the past
Case Study on Page 7
What nursing diagnosis is appropriate at the time? - ANS Deficient knowledge about therapy
with iron supplements
Self-health management, readiness for enhanced
Case study on page 7
3) What is missing, what should be done? - ANS Think about the "Nine Rights"! Assuming the
prescription has her name on it (right patient), and the licensed prescriber's signature (right
documentation), the prescription has the drug name (right drug), 325 mg (right dose), PO (right
route), and right reason (for anemia), but something is missing! The right TIME. How often does
this medication need to be taken? Should it be taken with meals or on an empty stomach? The
pharmacist will need to contact the licensed prescriber to clarify the prescription. The frequency
of the medication will certainly affect the dosage she ultimately receives each day.
Case study page 7
How should the nurse Handle this? - ANS Dollie has the right to refuse to take the medication.
However, the nurse needs to identify Dollie's reasons for refusing the medication. If the "cause"
of refusal is known, then the nursing care plan may be revised and further actions implemented,
such as education about the purpose of the drug and how to manage side effects, as well as
other concerns raised by the patient. In addition, the licensed prescriber should be notified of
Dollie's concerns, and the data should be documented, including information about the nurse's
response to Dollie's concerns.
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