9/1/2012 12:02:00 AM NURSING PROCESS: 1. ASSESSMENT 2. DIAGNOSIS 3. PLANNING 4. IMPLEMENTATION 5.

EVALUATION SUBJECTIVE DATA VS OBJECTIVE DATA Objective data= can be observed The big O= Observed Seen by te nurse, such as moist rales in a lung, lesions on the body, vital signs or lab tests Subjective data= Has to be stated (said) by the patient The big S= Stated (by the patient) ABC METHOD (PRIORITIES) A= AIRWAY B= BREATHING C= CIRCULATION INDEPENDENT VS DEPENDENT INTERVENTION Independent nursing intervention= based on nursing knowledge Dependent nursing intervention= based on a specific physician order EVALUATION SBAR S = Situation: Describe the current problem. B = Background: Give the doctor a rundown on the patient (admission diagnosis and vital signs, treatments, previous lab results, or whatever is relevant). A = Assessment: Share conclusions (based on assessment) about the patients problem. R = Recommendation: Offer a statement of what you believe would be helpful to remedy the patients problem.

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9/1/2012 12:02:00 AM The Five Rights - Right medication. Compare drug card, medication sheet or drug kardex (clients medication record) three times, with label on drug container. Know action, dosage and method of administration. Know side effects of the drug. - Right client Check the clients identification-Name, DOB, allergies - Right time - Right method/route of administration - Right amount/dosage check dose calculations Application of Nursing Process - Assessment /Data base - Assess route for drug administration - Assess specific drug action for cheat - Observe for sign and symptoms of side effects or adverse reactions - Assess need for and accuracy of drug calculation