NAPA VALLEY COLLEGE
ASSOCIATE DEGREE PROGRAM
NURS 143
MEDICATION ASSIGNMENT GUIDELINES
A. General Instructions
1. Use prep packets available in bookstore.
2. List all drugs ordered: trade (add generic) name, dose, frequency, route, times to be given, and safe range.
3. Giving meds includes giving all meds except IV meds.
4. Preparation prior to clinical includes reviewing carefully:
a. The medication procedure for that hospital (see nursing procedure books in skills lab and on each hospital unit).
b. Drug information: classification, action, side effects, why ordered for given patient, actual M.D. order, nursing implications, expected outcome and evaluation.
B. Med Sheet Format:
1. Action
State simple action (i.e. what it does), not the mechanism (how it does it). For some drugs, class and action are the same (i.e., diuretic). Example: the action of digitalis is to decrease heart rate, increase cardiac output and increase force of contraction.
2. Why ordered
This is the key to being able to evaluate the effectiveness of a drug. Avoid repeating the action, use or overall goal. State what medical diagnosis or problem you found documented for this patient that supports why the drug was ordered.
3. Side Effects
Two or three, which seem most likely are adequate for this worksheet. It is often useful to group side effects rather than spell them out (i.e., GI distress – N & V, diarrhea, cramps).
4. Nursing Implications
Again, choose one or two pertinent items for this patient. Omit repeating to check for side effects, since this is always the case.
The implications should pertain only to this patient. They should pertain to the route used. For example: is the medication being given to your patient to lower blood pressure or cause diuresis?
5. Expected Outcome
These are always measurable. First, look at “why ordered,” which is the key for this area. State those data or facts you will look at to determine if the medication is solving the problem. Digoxin, ordered to treat congestive heart failure, could have these expected outcomes: lungs clear, no edema, JVD, or pulse deficit, etc. These parameters could vary with each patient.
If you are having difficulty with outcomes, ask your instructor for assistance. Outcomes are to be filled out prior to clinical. Remember, they directly relate to “why ordered.” If this is unknown, outcomes are not possible to determine.
6. Evaluation
Ideally, should be completed at the end of each clinical day. At least fill these in by the second day. Evaluations are done by simply listing the actual findings/data/facts listed as listed under expected outcomes. If outcomes are stated properly, then anyone could collect the data. State facts only, no judgments or conclusions. Example: if the expected outcome is decreased H.R., you will simply state what the heart rate is (HR 70).
Outcome: regular rhythm
Eval: Irregular pulse (or regular)
Outcome: afebrile
Eval: Temp. 100°
Outcomes (for prn): “relief” (quotes mean indicated patient statement).
Eval: used x 1 for c/o H/A without relief OR used x 2 for incisional pain with relief
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