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Nursing Process Use the nursing process to prevent medication errors. Assessment/data collection Ensure knowledge of medication to administer and why. Obtain information about the clients' medical diagnoses and conditions that relate to medication administration (the ability to swallow, diet, allergies, contraindications, and heart, liver, and kidney disorders). Identify allergies. Obtain necessary pre-administration data (heart rate, blood pressure, laboratory data) to assess the appropriateness of the medication and to obtain baseline data for evaluating the effectiveness of medications. Omit or delay doses if indicated according to findings and notify the provider. Determine if the medication prescription is complete: with the client's name, date and time, name of medication, dosage, route of administration, time and frequency, and signature of the prescribing provider. Interpret the medication prescription accurately. Refer to the ISMP lists for error-prone abbreviations, confused medication names, and high-alert medications. Question the provider if the prescription is unclear or seems inappropriate for the client's condition. Refuse to administer a medication if it seems unsafe and notify the charge nurse or supervisor. Providers usually make dosage changes gradually. Question the provider about abrupt and excessive changes. Determine clients' learning needs. Planning Identify clients' outcomes for medication administration. Prioritize medication administration to administer.
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