lOMoARcPSD|26582732
NSG 318 TOPIC 1 NOTES 2025
Unit 1 – introduction to pharmacology
Chapter 1: the nursing process and patient-centered care
• Nursing process used by nurses for appropriate delivery of patient care and drug
administration
• Describes the who, what, where, when, why and how of nursing practice
• Supports prioritizing safe nursing care and medication administration
• 40 % of nurse’s time is spent administering medication
The nursing process
• Six-step decision-making approach that includes
1. Concept
2. Assessment
3. Patient problem (replaces diagnosis)
4. Planning
5. Implementation (nursing intervention)
6. Evaluation
• Purpose is to identify a patient’s problem and provide care
• Continuous and moves back and forth between the various steps
Nursing process: patient-centered collaborative care
• Concept
o Centers its focus for nursing care around the reason the care is being provided
to the patient
o Holistic view of the patient rather than the disease model o includes health,
illness, and health promotion of the patient o involves preventative, primary,
acute and chronic health care for the ill patient o nurse provides patient
education, restorative health needs, medication administration, and possibly
emergency care
• Concept: clinical decision making o understanding and organizing a patient’s health
problems and taking necessary action by using the nursing process to achieve successful
outcomes
o
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o
• Assessment
o During this phase, nurse gathers information from the patient about the
patient’s health and lifestyle
o Includes both subjective and objective data
Nurse should perform a complete systemic assessment of the patient’s body
systems
Nurse asks the patient questions about their illness, including the drug regimen
o nurse can also obtain information from family members, health professionals,
and the medical record
o This phase is paramount because the nurse will use the information gathered to
form the basis of the patient’s plan of care
• Subjective data o includes information provided verbally by the patient, family
members, friends, or other sources
o Patient must verbalize subjective data, which are imperceptible by the nurse’s
senses
o Based on what patients or family members communicate to the nurse o nurse
may ask open-ended questions, allowing the patient to answer directly, such as
“please tell me about your current medications”
o Nurse may help the patient explain or describe subjective data but must never
speak for the patient
o Comprises what the patient personally has to say about his or her medications,
health problems, and lifestyle
o Examples of information that the nurse can use:
Inquire about patient’s current health history, including family history
question whether or not the patient has problems swallowing
( dysphagia )
Have the patient verbalize signs and symptoms of his or her illness
discuss the patient’s current health concerns:
• Knowledge of medications and side effects
• Over-the-counter (otc) remedies, nutritional supplements, herbal remedies, and
contraceptives
• Knowledge of side effects to report to the physician
• Attitude and beliefs about taking medications
• Allergies
• Financial barriers
• Use of tobacco, alcohol, and caffeine
o
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, lOMoARcPSD|26582732
o
• Cultural dietary barriers
• The patient’s home safety needs caregiver needs and support system
o Enhancing patient’s adherence to their drug therapy regimen is an essential
component of health teaching
o Patient’s attitude and values about taking medication is an important
consideration when determining readiness to learn
o Attitude and values should be considered when planning interventions to
support the patient’s decision to adopt healthy behaviors related to their
medications
Patient’s social support system should be emphasized
Special support system is unique to the individual and may be composed of
persons who assist in preparing, organizing, and ordering medications
o Support system can alert a patient to side effects, encourage actions that
promote medication compliance, and notify the health care provider if a
problem arises
• Objective data o what the nurse directly observes about the patient’s health status o
involves collecting the patient’s health information by using personal senses: seeing,
hearing, smelling, and touching
o Collection provides additional information about the patient’s symptoms and
also targets the organs most likely to be affected by drug therapy
o Examples of objective data assessed by the nurse concerning medication
administration:
Physical health assessment
Laboratory and diagnostic test results
Data from the physician’s notes (i.e., health history)
Measurement of vital signs
The patient’s body language
• Patient problem o made based on analysis of the assessment data o determines the
type of care the patient will receive
o If there is an abnormality during the assessment, it can serve as the defining
characteristic of a problem
o More than one applicable problem can be generated
o Nurse formulates to patient problem, which guides the development of the plan
of care to provide patient-centered quality care
o Common problems related to drug therapy:
o
Downloaded by NELSON KIIRU ()
NSG 318 TOPIC 1 NOTES 2025
Unit 1 – introduction to pharmacology
Chapter 1: the nursing process and patient-centered care
• Nursing process used by nurses for appropriate delivery of patient care and drug
administration
• Describes the who, what, where, when, why and how of nursing practice
• Supports prioritizing safe nursing care and medication administration
• 40 % of nurse’s time is spent administering medication
The nursing process
• Six-step decision-making approach that includes
1. Concept
2. Assessment
3. Patient problem (replaces diagnosis)
4. Planning
5. Implementation (nursing intervention)
6. Evaluation
• Purpose is to identify a patient’s problem and provide care
• Continuous and moves back and forth between the various steps
Nursing process: patient-centered collaborative care
• Concept
o Centers its focus for nursing care around the reason the care is being provided
to the patient
o Holistic view of the patient rather than the disease model o includes health,
illness, and health promotion of the patient o involves preventative, primary,
acute and chronic health care for the ill patient o nurse provides patient
education, restorative health needs, medication administration, and possibly
emergency care
• Concept: clinical decision making o understanding and organizing a patient’s health
problems and taking necessary action by using the nursing process to achieve successful
outcomes
o
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
o
• Assessment
o During this phase, nurse gathers information from the patient about the
patient’s health and lifestyle
o Includes both subjective and objective data
Nurse should perform a complete systemic assessment of the patient’s body
systems
Nurse asks the patient questions about their illness, including the drug regimen
o nurse can also obtain information from family members, health professionals,
and the medical record
o This phase is paramount because the nurse will use the information gathered to
form the basis of the patient’s plan of care
• Subjective data o includes information provided verbally by the patient, family
members, friends, or other sources
o Patient must verbalize subjective data, which are imperceptible by the nurse’s
senses
o Based on what patients or family members communicate to the nurse o nurse
may ask open-ended questions, allowing the patient to answer directly, such as
“please tell me about your current medications”
o Nurse may help the patient explain or describe subjective data but must never
speak for the patient
o Comprises what the patient personally has to say about his or her medications,
health problems, and lifestyle
o Examples of information that the nurse can use:
Inquire about patient’s current health history, including family history
question whether or not the patient has problems swallowing
( dysphagia )
Have the patient verbalize signs and symptoms of his or her illness
discuss the patient’s current health concerns:
• Knowledge of medications and side effects
• Over-the-counter (otc) remedies, nutritional supplements, herbal remedies, and
contraceptives
• Knowledge of side effects to report to the physician
• Attitude and beliefs about taking medications
• Allergies
• Financial barriers
• Use of tobacco, alcohol, and caffeine
o
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
o
• Cultural dietary barriers
• The patient’s home safety needs caregiver needs and support system
o Enhancing patient’s adherence to their drug therapy regimen is an essential
component of health teaching
o Patient’s attitude and values about taking medication is an important
consideration when determining readiness to learn
o Attitude and values should be considered when planning interventions to
support the patient’s decision to adopt healthy behaviors related to their
medications
Patient’s social support system should be emphasized
Special support system is unique to the individual and may be composed of
persons who assist in preparing, organizing, and ordering medications
o Support system can alert a patient to side effects, encourage actions that
promote medication compliance, and notify the health care provider if a
problem arises
• Objective data o what the nurse directly observes about the patient’s health status o
involves collecting the patient’s health information by using personal senses: seeing,
hearing, smelling, and touching
o Collection provides additional information about the patient’s symptoms and
also targets the organs most likely to be affected by drug therapy
o Examples of objective data assessed by the nurse concerning medication
administration:
Physical health assessment
Laboratory and diagnostic test results
Data from the physician’s notes (i.e., health history)
Measurement of vital signs
The patient’s body language
• Patient problem o made based on analysis of the assessment data o determines the
type of care the patient will receive
o If there is an abnormality during the assessment, it can serve as the defining
characteristic of a problem
o More than one applicable problem can be generated
o Nurse formulates to patient problem, which guides the development of the plan
of care to provide patient-centered quality care
o Common problems related to drug therapy:
o
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