Collaboration in Community Settings
Objectives
• Describe common elements of patient teaching about medication administration in community settings.
• Explain specific points related to administration of medications in the home.
• Discuss specific points related to administration of medications in the school.
• Describe specific points related to administration of medications in the work site.
• Explain the application of the nursing process to medication administration in community settings.
Health and illness care has shifted from traditional institutions to community settings. The faces of a community are many, varied, and ever-changing. With the movement of health care into the community, nurses—more than any other health care provider—have the opportunity to shape the health care of society. This chapter describes selected aspects of medication administration of prescription, over-the-counter (OTC), and herbal preparations within each of the major community settings: home, school, and work. In all settings, patient safety is the primary concern. (Refer to Chapter 13 for a detailed discussion of medication administration.)
This chapter discusses a small, but significant, portion of the nurse’s role in a variety of community settings. Specifically, the focus is on selected concerns associated with the administration of medications and the need to practice in accordance with the Nurse Practice Act of a specific state. The role of the nurse in drug administration is growing in complexity. Most medications are taken by community-dwelling residents (not hospitalized patients), which clearly shows the importance of patient education in all settings. The nurse in the twenty-first century must have a strong knowledge base.
The process of medication administration in the home, school, and work site must be consistent with professional, legal, and regulatory requirements. In each setting, it must first be determined what the nursing personnel will teach patients about medications and then the routes by which the medications can be administered. Once these decisions have been made, criteria for administration, instruction and patient teaching, and ongoing supervision must be developed, implemented, and evaluated. Mechanisms for communication and electronic or paper tracking must be in place to promote efficacy of the medication and avoidance of untoward responses and medication errors.
With the escalating costs of medications, the nurse in any community setting is likely to meet patients who need assistance paying for their prescriptions. A possible resource for the nurse and patient are pharmaceutical companies’ patient-assistance programs (PAPs). Some PAPs provide medications for free or at a reduced cost, but often patients must demonstrate that they do not qualify for private or public health insurance and that their income is below a certain level. An application process is required; the health care provider, nurse, or social worker may need to apply for the patient. Online resources that assist in finding PAPs or other programs include rxassit.org (sponsored by Volunteers in Health Care), RxHope.com (supported by the Pharmaceutical Research and Manufacturers of America), and PPARx.org (Partnership for Prescription Assistance).
The backbone of health promotion and disease prevention is the patient knowledge base. The role of the nurse in establishing this base is critical. (A comprehensive discussion of patient teaching is offered in Chapter 11.) Assessment of learning needs and styles is another essential component to achieving the identified teaching goal.
Patient Teaching
Regardless of the state and agency regulations related to medication administration in community settings, the following format for patient teaching associated with medication administration is recommended. Hints are grouped into five categories: (1) general, (2) diet, (3) self-administration, (4) side effects, and (5) cultural considerations.
General
Patient safety is of primary concern, so a patient’s physical abilities require ongoing assessment. Capabilities of the patient may be temporarily impaired with the use of certain drugs (e.g., narcotics, selected eye medications, psychotropics). It is essential that patients be advised not to drive a vehicle or operate hazardous machinery during such times and to use caution at all other times. It is appropriate to discuss with patients and families what situations in the daily routine require full alertness and cannot be influenced by medication for the sake of safety.
Numerous safety concerns are associated with the storage of medications. Medications should be kept in their original labeled containers, with childproof caps when needed, and stored away from light and moisture.
Advise the patient and family about any necessary laboratory tests to monitor the blood level of the medication and any possible drug-laboratory test interactions. Also educate the patient and family about assessments—such as heart rate, blood pressure, or blood sugar levels—that should be done before taking the medication. This information, and all other information about the drug regimen, should be provided as written instructions (or audio instructions if the patient is sight impaired or unable to read). Large print may be helpful or necessary.
Important yet frequently misunderstood components of the instructions are the expected therapeutic effect and the length of time required to achieve a therapeutic response from the medication. These vary widely among different medications (e.g., most opioids act within 30 minutes; many antibiotics act within 24 hours; some psychotropics act within 6 weeks). Patient understanding of the expected time frame for results can markedly diminish concerns and promote adherence to the therapeutic plan.
The patient and family must also be aware of the need to have an adequate supply of necessary medications available at all times: at home, school, work, and while traveling. It is best to order prescription refills in advance. If the pharmacy is local, at least 1 week should be allowed; several weeks should be allowed if drugs are ordered through the mail. It is a good idea to pack extra medication when going on trips, both short and extended. This is preferred at all times and is essential for foreign travel.
Advise the patient and family to contact the health care provider before using OTC preparations. Common OTC preparations that may cause problems are laxatives, diet aids, cold and cough preparations, nonsteroidal anti-inflammatory drugs (NSAIDs), antacids, and medications for sleep. Reinforce with the patient and family the importance of follow-up appointments with health care providers. Encourage wellness checkups, including preventive and restorative dental care, because the presence of other conditions may affect the current therapeutic regimen. In addition, advise patients of the need to complete laboratory studies in a timely manner. Encourage patients to wear medical alert bands that indicate the patient’s condition or disease (e.g., diabetes, parkinsonism), medications, and allergies (Herbal Alert 9-1). See Chapter 12 for guidelines on the safe disposal of drugs.
Herbal Alert 9-1
Community
Encourage the patient to consult the health care provider before taking herbal preparations or vitamin and mineral supplements; some products may interact with prescription or over-the-counter medications.
Reinforcement of the availability of community resources is important. Availability does not always equate with accessibility, so the patient or family needs to know how to mobilize resources according to individual needs. Matching community resources and patient needs is a prerequisite. While acknowledging the variability of each patient, family, and setting need, the following are offered as examples:
• Pharmacists can frequently clarify a patient’s or family’s concern over the telephone.
• Meals on Wheels enables patients to remain at home and adhere to taking medications with food.
Patients or families need to be encouraged to have a contact person for their concerns and questions, frequently a nurse. Use of appropriate resources is likely to increase compliance with and effectiveness of the therapeutic regimen.
Diet
Nurses should advise patients or families about possible drug-food interactions, detailing which foods are to be avoided and which foods are encouraged for specific nutrient value. For example, tyramine-rich foods are contraindicated with monoamine oxidase inhibitors (MAOIs), and potassium-rich foods are recommended for patients taking potassium-wasting diuretics. Alcohol may be contraindicated with selected medications. Lists of foods, with pictures when appropriate, may be helpful to patients and their families.
Self-Administration
Based on the level of the patient’s or family’s knowledge, instructions should be given on all skills related to the drug regimen, how to take the pulse for patients who take digitalis preparations, how to use and clean inhalers, how to administer parenteral medications, and how to decrease the risk for infection in patients taking immunosuppressants. The nurse should allow time for instruction and questions, including demonstration of the skill and return demonstration. Patients should be given graphic illustrations for future reference as appropriate. It is essential that the nurse provide the patient or family with the name and telephone number of a contact person for questions and concerns. It is not uncommon for a patient or family member to return-demonstrate a skill (e.g., administration of insulin, use of inhaler) with relative ease and then forget information or become confused when attempting self-administration of the drug while alone. Resources must be provided to the patient and family if this occurs.
Side Effects
The patient or family should be advised about general side effects of medications. This is not done to scare patients but rather to let them know what they might expect. Patients should know when and how to notify their health care provider if they experience an adverse reaction; this information should be kept in an easily accessible location for ready access if needed.
Cultural Considerations
Initially, the nurse assesses the patient’s personal beliefs. Based on these beliefs, the nurse then modifies communication to meet patient and family cultural practices. The nurse should communicate respect for the patient or family culture at all times. It is important for the nurse to assess his or her own beliefs and biases related to cultural competence and diversity, and then evaluate the effectiveness of interactions and their acceptability within the cultural realm. Culturally sensitive and competent health care promotes patient and family adherence to the therapeutic regimen. Respect for cultural diversity may be demonstrated by inclusion of traditional practices into the plans for improved communication, health promotion, and disease prevention. Refer to Chapter 3 for a discussion of cultural differences.
Community-Based Settings
Home Setting
The home setting provides nurses with opportunities and challenges related to medication administration. The patient and family are generally more comfortable in their home; the nurse is a guest. The nurse has a comprehensive view of the patient and family during a home visit (e.g., support system, resources, adherence). A question that may quickly arise is, “Who can administer medications in the home setting?” The response does not develop so quickly.
In general, medications are administered by licensed nurses in the home setting according to the health care provider’s order. Drugs that are administered by nursing personnel in the home must be approved by the U.S. Food and Drug Administration (FDA). The nurse must provide instructions about the medication to the patient and family. The licensed nurse may also administer the medication on a short-term basis for a disease-related condition if the patient or a caregiver with an order from the health care provider is unable to do so.
The order from the health care provider must be current and complete (drug, dosage, frequency, route of administration, and signature). The medication must be labeled by the pharmacist or health care provider; the nurse should not administer any medication that is not properly labeled. It is the nurse’s responsibility to contact the health care provider, pharmacist, or other contact identified by the agency with any concerns about the medication for a specific patient. The expiration date must be checked at the time of each administration. Storage and deterioration of the medication are also evaluated. Significant side effects, allergies, and adverse reactions are reported promptly to the health care provider. Each patient is assessed for allergies before administering the drug.
The establishment of policy and procedures for medication administration promotes safety and consistency; however, errors do occur. When a medication error occurs, it is reported to the health care provider and nursing supervisor. The patient and family are instructed when to notify the nurse or health care provider if an adverse drug reaction is suspected. Ultimately, the health care provider should be notified of all adverse drug reactions.
Safety: Preventing Medication Errors
Community Settings
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