| ADMINISTERING ORAL MEDICATIONS | 口服給藥 |
| Assessment | 評(píng)估 |
| 1. Identify the drug（s） ordered: action, purpose, normal dosage and route, common side effects, time of onset and peak action, and nursing implications. | 確認(rèn)藥物：作用、目的、正常劑量及給藥途徑、常見(jiàn)副作用、起效時(shí)間和藥峰時(shí)間和護(hù)理 |
| 2. Assess for any contraindications to oral medication. | 評(píng)估口服藥物禁忌 |
| 3. Check allergies and replace any missing or faded identification bracelets. | 核對(duì)過(guò)敏資料，補(bǔ)充遺失或替換模糊的識(shí)別腕帶?！?/td> |
| 4. Assess client's knowledge regarding medications. | 評(píng)估病人的藥物知識(shí)?！?/td> |
| 5. Assess client's preferences for fluids. Maintain fluid restrictions as prescribed. | 評(píng)估病人液體喜好。按處方維持液體限制?！?/td> |
| Implementation | 實(shí)施 |
| 1. Use Standard Protocol. | 使用標(biāo)準(zhǔn)儀式?！?/td> |
| Preparing medications | 準(zhǔn)備藥物 |
| 2. Compare medication administration record with scheduled medication list. If discrepancies exist, check against original physician orders. | 對(duì)照用藥記錄與藥物單。如有差錯(cuò)，應(yīng)核對(duì)原始醫(yī)囑?！?/td> |
| Nurse Alert: Review five rights. | 注意：執(zhí)行“五對(duì)”制度?！?/td> |
| 3. Arrange cups in medication preparation area or move medication cart to position outside client's room. | 在藥物準(zhǔn)備區(qū)備好杯子，或?qū)⑺庈?chē)推到病人病房外?！?/td> |
| 4. Unlock medicine drawer or cart. | 開(kāi)鎖，打開(kāi)藥柜或藥車(chē)。 |
| 5. Prepare medications for one client at a time. | 按病人依次準(zhǔn)備藥物?！?/td> |
| 6. Select correct drug from stock supply or unit dose drawer. Compare label of medication with MAR or computer printout. | 從備用藥或單位劑量抽屜中選擇所需藥物。 |
| 7. Check drug dose. If label dose differs from ordered dose, calculate correct amount to give. | 核對(duì)藥物劑量。如標(biāo)簽劑量不同于醫(yī)囑劑量，應(yīng)算出正確劑量?！?/td> |
| 8. To prepare unit dose tablets or capsules, place packaged tablet or capsule directly into medicine cup without removing wrapper. | 準(zhǔn)備單位劑量藥片或膠囊時(shí)，直接將包裝好的藥片或膠囊放入藥杯，無(wú)需除去包衣。 |
| 9. To prepare tablets or capsules from a floor stock bottle, pour required number into bottle cap and transfer medication to medication cup. Do not touch medication with fingers; return extra tablets or capsules to bottle. | 從原料瓶準(zhǔn)備藥片或膠囊時(shí)，將所需藥物倒入瓶蓋，現(xiàn)轉(zhuǎn)到藥杯，勿使手指觸碰藥品物。將剩余藥片或膠囊倒回藥瓶?！?/td> |
| 10. Check the expiration date of each drug. Return all outdated drugs to pharmacy. | 核對(duì)每種藥物的有效期。將過(guò)期藥品退還藥房?！?/td> |
| 11. Place all tablets or capsules requiring preadministration assessments （e.g., pulse rate, blood pressure） in a separate cup. | 將需要進(jìn)行藥前評(píng)估的藥品（如脈率、血壓）單獨(dú)放在一個(gè)杯中?！?/td> |
| 12. Medications that need to be broken in order to administer half the dose can be broken using a gloved hand or cut with a cutting device. | 需切半服用的藥物可用帶手套手掰開(kāi)或用銳器切開(kāi)?！?/td> |
| 13. When preparing liquids, thoroughly mix before administering. Check and discard medications that are cloudy or have changed color: | 液體藥：用前需搖勻。檢查并棄用混濁或變色藥品?！?/td> |
| A. Place cap upside down while pouring. | 傾倒藥液時(shí)將蓋底朝上?！?/td> |
| B. Hold label against palm of hand while pouring. | 倒時(shí)就用手心貼住標(biāo)簽?！?/td> |
| C. Place medication cup at eye level and fill to desired level. | 持藥杯與眼同高，倒藥液至所需刻度處。 |
| D. Wipe lip of bottle with paper towel. | 用紙巾擦凈瓶口?！?/td> |
| E. If client has difficulty swallowing, use a mortar and pestle to grind pills or a pill-crushing device. Mix ground tablet in small amount of soft food. | 如病人呑藥有困難，可用藥臼或碎藥器研碎藥片。用少量軟食混合藥末?！?/td> |
| 14. If giving less than 5 ml of liquids, prepare medication in a sterile syringe without a needle. | 如所給藥液少于5毫升，可用無(wú)針頭注射器準(zhǔn)備藥液?！?/td> |
| Nurse Alert: EC or SR tablets may be available in liquid or suppository form. Crushing alters absorption rate. | 注意：腸衣片或緩釋制劑分液劑和栓劑，研碎后可改變吸收率?！?/td> |
| 15. Narcotic preparation. Check narcotic record for previous drug count and compare with supply available. | 麻醉藥品。核對(duì)用藥記錄，檢查以前用藥數(shù)量及可用藥品。 |
| 16. Sign out narcotics according to agency policy. | 根據(jù)醫(yī)院規(guī)定登記麻醉藥品使用情況?！?/td> |
| Administering medications | 發(fā)藥 |
| 17. Take medications to client within 30 minutes before or after scheduled time. | 在預(yù)定給藥時(shí)間30min內(nèi)攜藥品至病人床前?！?/td> |
| 18. Identify client. | 確認(rèn)病人?！?/td> |
| 19. Perform necessary preadministration assessment for specific medications. | 實(shí)施特定藥品的用前評(píng)估?！?/td> |
| 20. Discuss the purpose of each medication and its action with client. Allow client to ask any questions about drugs. | 與病人討論每種藥品的用藥目的及其作用。允許病人詢問(wèn)藥品相關(guān)問(wèn)題?！?/td> |
| 21. Assist client to sitting or side-lying position. | 協(xié)助病人取坐位或側(cè)臥位?！?/td> |
| Nurse Alert: Check ability to swallow if appropriate. | 注意：檢查呑藥能力?！?/td> |
| 22. Administer drugs properly: | 正確給藥： |
| A. Client may wish to hold solid medications in hand or cup before placing in mouth. | 病人可能會(huì)在藥品放入口前將固體藥品放在手里或杯中?！?/td> |
| B. If client is unable to hold medications, place medication cup to the lips and gently introduce each drug into the mouth, one at a time. Do not rush. | 如病人無(wú)法持藥，可將藥杯放在病人唇邊，輕輕將藥片喂進(jìn)嘴里，一次一片。不要倉(cāng)促行事?！?/td> |
| C. Offer water or juice to help client swallow medications. Give cold carbonated water if available and not contraindicated. | 用水或液體幫助病人呑藥。如無(wú)禁忌，也可用碳酸水送服?！?/td> |
| Nurse Alert: Decide on sequence of administration. | 注意： |
| D. For sublingual-administered drugs, have client place medication under tongue and allow it to dissolve completely. Caution client against swallowing tablet. | 服舌下藥時(shí)，應(yīng)讓病人將藥放于舌頭下待其完全溶化。提醒病人不能呑藥。 |
| E. For buccal-administered drugs, have client place medication in mouth against mucous membranes of the cheek until it dissolves. | 頰部給藥時(shí)，應(yīng)讓病人將放入口腔貼在面頰粘膜直至溶化。 |
| F. Mix powdered medications with liquids at bedside and give to client to drink. | 在床邊用液體混合粉劑給病人服用。 |
| G. Caution client against chewing or swallowing lozenges. | 提醒病人不能咀嚼或呑咽錠劑?！?/td> |
| H. Give effervescent powders and tablets immediately after dissolving. | 泡騰粉劑和片劑應(yīng)在溶解后立即服用。 |
| 23. Stay until client has completely swallowed each medication. If concerned about ability or willingness to swallow, ask client to open mouth and inspect for presence of medication. | 確認(rèn)病人服下全部藥品后方可離開(kāi)。如擔(dān)心病人呑咽能力或不愿意呑咽藥品，應(yīng)要求病人張嘴檢查口腔內(nèi)是否存有藥品。 |
| 24. For certain medications that should not be given on an empty stomach, offer client nonfat snack. | 有些藥物不能空腹服用，服用時(shí)應(yīng)向病人提供非脂肪食物?！?/td> |
| 25. Replenish stock such as cups and straws, return cart to medicine room, and clean work area. | 補(bǔ)充用口，如藥杯和吸管。推車(chē)返回藥房，清潔工作區(qū)?！?/td> |
| 26. Use Completion Protocol. | 使用完成儀式?！?/td> |
| Evaluation | 評(píng)價(jià) |
| 1. Return within appropriate time to determine client's response to medications. | 及時(shí)返回病房確定病人對(duì)藥物的反應(yīng)?！?/td> |
| 2. Evaluate client's learning needs. | 評(píng)價(jià)病人學(xué)習(xí)需要。 |
| Identify Unexpected Outcomes and Nursing Interventions | 確認(rèn)意外結(jié)果和護(hù)理措施?！?/td> |
| Record and Report | 記錄和報(bào)告 |
| 1. Actual time given and signature according to agency policy. | 按醫(yī)院規(guī)定登記實(shí)際給藥時(shí)間及簽名?！?/td> |
| 2. Drugs withheld and reason. | 停用藥物及理由?！?/td> |
| 3. Adverse effects/client response. | 不利效應(yīng)及病人反應(yīng)?！?/td> |
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