Assessment:
Compare medications listed against physician’s orders. Assess psychological and physical status, weight, age, height. Assess ability to swallow medications. Check form of medications available and computes for a safe dosage. Check which vehicles are available for mixing with medications.
Planning:
Plan a method of measuring medication accurately, making medication acceptable to patient, approaching patient appropriately, restraining, if necessary. Determine need for special preparation. Determine needed equipment. Wash hands observing proper technique. Gather needed equipment.
Implementation:
Read from chart/kardex the name of drug ordered. Take drug from shelf, drawer or cubicle, checking label before picking it up. Check label and expiry date on medication. Check label again, with the medication ticket before removing the medication from the container. Prepare correct amount of medication. Pour correct Amount to medicine cup, while keeping bottle facing up. Wipe neck of bottle before replacing cap. Return bottle to shelf, drawer, cubicle or refrigerator, checking label the third time. Place medication on cart or tray with medication card/ticket. Approach and identifies patient through wrist ID or letting him state his name. Explain what to do to patient or watcher and any pertinent specifies related to drug. Add appropriate planned actions related to making medication acceptable to patient. Assist, if necessary, to a comfortable position for taking the drug. Restrain, if necessary. Give medication with a glass of water or juice, if not contraindicated. Watch to make sure medications was properly taken. Leave patient in comfortable position. Perform appropriate aftercare of medication containers, trays and tickets. Wash hands.
Evaluation:
The right patient received the right medication in the right dosage by the right dosage by the right route at the right time. The criteria, specified in the plan of care (NCP) established for ascertaining the effectiveness of a specific drug were used. Side effect, if present, were promptly identified and recorded. Necessary referrals were made.
Documentation:
Record appropriately according to the policy of the facility.
