Nursing Process Guidelines
The delivery of medical care is in a constant state of change and sometimes in crisis. The population is aging, resulting in more chronic disease and more complex care issues. The population is transient, resulting in unstable support systems and fewer at-home care providers and helpers. At the same time, medicine is undergoing a technological and pharmacological boom. Patients are being discharged earlier from the acute-care facility or not being admitted at all for procedures that used to be done in the hospital with follow-up support and monitoring. Patients are becoming more responsible for their own care and for following complicated medical regimens at home.
Nursing is a unique and complex science and a nurturing and caring art. Traditionally, nurses minister to and soothe the sick; currently, nursing also requires using more technical and scientific skills. Nurses have had to assume increasing responsibilities involved not only with nurturing and caring, but also with assessing, diagnosing, and intervening with patients to treat, prevent, and educate to help people cope with various health states.
The nurse deals with the whole person—the physical, emotional, intellectual, and spiritual aspects—considering the ways that a person responds to disease and treatment, and the change in lifestyle that may be required by both. The nurse is the key health care provider in a position to assess the patient (physical, social, and emotional aspects), administer therapy and medications, teach the patient how best to cope with the therapy to ensure the most effectiveness, and evaluate the effectiveness of therapy. This role requires a broad base of knowledge in the basic sciences (anatomy, physiology, nutrition, chemistry, pharmacology), the social sciences (sociology, psychology), and education (learning approaches, evaluation).
Although all nursing theorists do not completely agree on the process that defines the practice of nursing, most include certain key elements in the nursing process. These elements are the basic components of the decision-making or problem-solving process: assessment (gathering of information), diagnosis (defining that information to arrive at some conclusions), planning (developing a plan of care), intervention (eg, administration, education, comfort measures), and evaluation (determining the effects of the interventions that were performed). Using this process each time a situation arises ensures a method of coping with the overwhelming scientific and technical information. However, the unique emotional, social, and physical aspects that each patient brings to the situation can confound matters. Using the nursing process format in each instance of drug therapy will ensure that the patient receives the best, most efficient, scientifically based holistic care.
Assessment
The first step of the nursing process is the systematic, organized collection of data about the patient. Because the nurse is responsible for holistic care, these data must include information about physical, intellectual, emotional, social, and environmental factors. They will provide the nurse with information needed to plan discharge, plan educational programs, arrange for appropriate consultations, and monitor physical response to treatment or to disease. In actual clinical practice, this process never ends. The patient is not in a steady state but is dynamic, adjusting to physical, emotional, and environmental influences. Each nurse develops a unique approach to the organization of the assessment, an approach that is functional, useful, and appropriate in the clinical setting and that makes sense to that nurse and that clinical situation.
Drug therapy is a complex, integral, and important part of health care today, and the principles of drug therapy need to be incorporated into every patient assessment plan. The particular information that is needed and that should be assessed will vary with each drug, but the concepts involved are similar and are based on the principles of drug therapy. Two important areas that need to be assessed are history and physical presentation.
History
Past experiences and past illnesses and surgeries impact the actual effect of a drug.
Chronic conditions: These may be contraindications to the use of a drug or may require that caution be used or that drug dosage be adjusted.
Drug use: Prescription drugs, over-the-counter (OTC) drugs, herbs and alternative therapies, street drugs, alcohol, nicotine, and caffeine all may have an impact on the effect of a drug. Patients often neglect to mention OTC drugs, herbal and alternative therapies, vitamin and mineral supplements, and contraceptives, not considering them actual drugs, and should be asked specifically about the use of OTC drugs, herbals, supplements, contraceptives, or any drug that might be taken on a long-term basis and not mentioned.
Allergies: Past exposure to a drug or other allergen can predict a future reaction or need to use certain drugs, food, or animal products cautiously.
Level of education: This information will help to provide a basis for patient education programs and level of explanation.
Level of understanding of disease and therapy: This information also will direct the development of educational information.
Social supports: Patients are being discharged earlier than ever before and often need assistance at home to provide care and institute and monitor drug therapy.
Financial supports: The financial impact of health care and the high cost of medications need to be considered when prescribing drugs. These factors may impact a patient’s ability to follow through with drug therapy.
Pattern of health care: The way that a patient seeks health care will give the nurse valuable information to include in educational information. Does this patient routinely seek physical examinations and follow-up care or wait for emergency situations?
Physical Assessment
Weight: Weight is an important factor when determining if the recommended dosage of a drug is appropriate. The recommended dosage is based on the 150-lb adult male. Patients who are much lighter or much heavier will need a dosage adjustment.
Age: Patients at the extremes of the age spectrum—pediatric and geriatric—often require dosage adjustments based on the functional level of the liver and kidneys and the responsiveness of other organs.
Physical parameters related to the disease state or known drug effects: Assessment of these factors before beginning drug therapy will give a baseline level with which future assessments can be compared to determine the effects of drug therapy. The specific parameters that need to be assessed will depend on the disease process being treated and on the expected therapeutic and adverse effects of the drug therapy. Because the nurse has the greatest direct and continual contact with the patient, the nurse has the best opportunity to detect the minute changes that will determine the course of drug therapy and therapeutic success or the need for discontinuation because of adverse or unacceptable responses.
The monographs in this book include the specific parameters that need to be assessed in relation to the particular drug being discussed (see the sample monograph in the preface). This assessment provides not only the baseline information needed before giving that drug, but the data needed to evaluate the effects of that drug on the patient. The information given in this area should supplement the overall nursing assessment of the patient, which will include social, intellectual, financial, environmental, and other physical data.
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