Nursing Assessment

The psychomotor domain involves learning physical skills (such as injection of insulin) or tasks (such as performing a dressing change). The nurse teaches a task or skill using a step-by-step method. The patient is allowed hands-on practice under die supervision of the nurse. The nurse assesses die patient mastery of the skill by having the patient or caregiver perform a return demonstration under the watchful eye of the nurse ... 

When developing a teaching plan die nurse assesses... 

The nurse should take and record vital signs. When appropriate, it is important to obtain a description of the signs and symptoms of the infection from the patient or family. The nurse assesses the infected area (when possible) and records finding on the patient s chart. It is important to describe accurately any signs and symptoms related to the patient s infection, such as color and lype of drainage from a wound, pain, redness and inflammation, color of sputum, or presence of an odor. In addition, the nurse should note the patient s general appearance. A culture and sensitivity test is almost always ordered, and the nurse must obtain the results before giving the first dose of penicillin. 

Identify nursing assessments that are performed when a drug is potentially nephrotoxic or ototoxic. 

ZIDOVUDINE The nurse assesses the patient for an increase in severity of symptoms of HIV and for symptoms... 

Before giving a nonnarcotic analgesic to a patient, the nurse assesses the type, onset, and location of the pain. It is important to determine if this problem is different in any way from previous episodes of pain or discomfort. If the patient is receiving a nonnarcotic analgesic for an arthritic or musculoskeletal disorder or soft tissue inflammation, the nurse should examine the joints or areas involved. The appearance of the skin over the joint or affected area or any limitation of motion is documented. The nurse evaluates the patient s ability to carry out activities of daily living. This important information is used to develop a care plan, as well as to evaluate the response to drug therapy. 

When administering acetaminophen, the nurse assesses the overall health and alcohol usage of the patient before administration. fatients who are malnourished or abuse alcohol are at risk of developing hepatotoxicity (damage to the liver) with the use of acetaminophen. 

During the ongoing assessment, the nurse monitors the patient for relief of pain. If pain recurs it is important to assess its severity, location, and intensity. The nurse monitors the vital signs every 4 hours or more frequently if necessary. Hot, dry, flushed skin and a decrease in urinary output may develop if temperature elevation is prolonged and dehydration occurs. The nurse assesses the joints for decrease in inflammation and greater mobility. 

It is especially important for the nurse to assess the type, location, and intensity of pain before administering the narcotic analgesic. Immediately before preparing a narcotic analgesic for administration, the nurse assesses the patient s blood pressure, pulse, and respiratory rate. 

The nurse assesses die patient for relief of pain about 30 minutes after a narcotic analgesic is given. It is important to notify the primary health care provider if die analgesic is ineffective because a higher dose or a different narcotic analgesic may be required. 

IM BALANCED NUTRITION. When a narcotic is prescribed for a prolonged time, anorexia (loss of appetite) may occur. Those receiving a narcotic for the relief of pain caused by terminal cancer often have severe anorexia from the disease and the narcotic. The nurse assesses food intake after each meal. When anorexia is prolonged, tiie nurse weighs the patient weekly or as... 

Discuss important preadministration and ongoing nursing assessments you would make when giving a patient naloxone for severe respiratory depression caused by morphine. 

When a patient is to receive an adrenergic agent for shock, the nurse obtains the blood pressure, pulse rate and quality, and respiratory rate and rhythm. The nurse assesses the patient s symptoms, problems, or needs before administering the drug and records any subjective or objective data on the patient s chart. In emergencies, the nurse must make assessments quickly and accurately. This information provides an important database that is used during treatment. 

MYASTHENIA GRAVIS. Once dierapy is under way, the nurse must document any increase in the symptoms of die disease or adverse drug reactions before giving each dose of the drug. The nurse assesses the patient for the presence or absence of die symptoms of myasdienia gravis before each drug dose In patients witii severe... 

If the patient is receiving one of these dru for daytime sedation, the nurse assesses die patient s general mental state and level of consciousness. If the patient appears sedated and difficult to awaken, the nurse withholds the drug and contacts the primary health care provider as soon as possible. 

PREVENT ING IN JU RY. After administration of a hypnotic, the nurse raises the side rails and advises the patient to remain in bed and to call for assistance if it is necessary to get out of bed. Fhtients receiving sedative doses may or may not require this safety measure depending on the patient s response to the drug. The nurse assesses the... 

A patient receiving an antipsychotic drug may be treated in the hospital or in an outpatient setting. The nurse assesses the patient s mental status before and periodically throughout therapy. The nurse must note the presence of hallucinations or delusions and document them accurately in the patient s record. 

The nurse assesses the patient at frequent intervals for the effectiveness of the drug to relieve symptoms (eg, nausea, vomiting, or vertigo). The nurse notifies the primary health care provider if the drug fails to relieve or diminish symptoms. 

If die antihistamine is given for a serious situation, such as a blood transfusion reaction or a severe drug allergy, the nurse assesses die patient at frequent intervals until the symptoms appear relieved and for about 24 hours after the incident. 

During tiie ongoing assessment, tiie nurse assesses the respiratory status every 4 hours and whenever tiie drug is administered. The nurse notes the respiratory rate, lung sounds, and use of accessory muscles in breathing, hi addition, tiie nurse keeps a careful record of the intake and output and reports any imbalance, which may indicate a fluid overload or excessive diuresis. It is important to monitor any patient with a history of cardiovascular problems for chest pain and changes in the electrocardiogram. The primary health care provider may order periodic pulmonary function tests, particularly for patients with emphysema or bronchitis, to help monitor respiratory status. 

Before administering the drug, the nurse assesses the respiratory status of the patient. The nurse documents lung sounds, amount of dyspnea (if any), and consistency of sputum (if present). A description of the sputum is important as a baseline for future comparison. 

Therapeutic results obtained from the administration of a peripheral vasodilating drug may not occur immediately. In some instances, results are minimal. The nurse assesses involved extremities daily for changes in color and temperature and records die patient s comments regarding relief from pain or discomfort. The nurse should monitor die blood pressure and pulse one to two times per day because tiiese dru may cause a decrease in blood pressure The anticipated result of tiierapy for cerebral vascular disease is an improvement in die patient s mental status. When die drug is taken for intermittent claudication, the nurse assesses the patient for increased walking distance without pain. 

The ongoing assessment of a patient receiving heparin requires close observation and careful monitoring. The nurse assesses vital signs every 2 to 4 hours or more frequently during administration. 

The nurse assesses the patient for relief of the symptoms of anemia (fatigue, shortness of breath, sore tongue, headache, pallor). Some patients may note a relief of symptoms after a few days of therapy. Periodic laboratory tests are necessary to monitor the results of therapy. 

If a carbonic anhydrase inhibitor is being given for absence or nonlocalized epileptic seizures, the nurse assesses the patient at frequent intervals for the occurrence of seizures, especially early in therapy and in patients known to experience seizures at frequent intervals. If a seizure does occur, the nurse records a description of the seizure in the patient s chart, including time of onset and duration. Accurate descriptions of the pattern and the number of seizures occurring each day helps the primary health care provider plan future therapy and adjust drug dosages as needed. 

When die miscellaneous drugs are administered, die nurse documents die symptoms the patient is experiencing to provide a baseline for future assessment. The nurse assesses for and documents pain, urinary frequency, bladder distension, or other symptoms associated widi die urinary system... 

The nurse assesses the patient receiving one of these drugp for relief of symptoms (such as diarrhea, pain, or constipation). The primary health care provider is notified if the drug fails to relieve symptoms. The nurse monitors vital signs daily or more frequently if the patient has a bleeding peptic ulcer, severe diarrhea, or other condition that may warrant more frequent... 

In addition, die nurse assesses and records die activity of die uterus (strengtii, duration, and frequency of contractions, if any). Monitoring of the uterine contractions for strengtii and length of die contractions can be done with the use of an external monitor or by an internal uterine catheter with an electronic monitor. A fetal monitor is placed to assess the FHR. 

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