The Nursing Process and Drug Therapy



The Nursing Process and Drug Therapy


Objectives


When you reach the end of this chapter, you will be able to do the following:



1 List the five phases of the nursing process.


2 Identify the components of the assessment process for patients receiving medications, including collection and analysis of subjective and objective data.


3 Discuss the process of formulating nursing diagnoses for patients receiving medications.


4 Identify goals and outcome criteria for patients receiving medications.


5 Discuss the evaluation process as it relates to the administration of medications and as reflected by goals and outcome criteria.


6 Develop a nursing care plan that is based on the nursing process as it relates to medication administration.


7 Briefly discuss the “Six Rights” associated with safe medication administration.


8 Discuss the professional responsibility and standards of practice for the professional nurse as related to the medication administration process.


9 Discuss the additional rights associated with safe medication administration.


Key Terms


Compliance Implementation or fulfillment of a prescriber’s or caregiver’s prescribed course of treatment or therapeutic plan by a patient. Use of compliance versus adherence in this textbook is supportive of the terms used in the current listing of NANDA-I nursing diagnoses. (p. 8)


Goals Statements that are time specific and describe generally what is to be accomplished to address a specific nursing diagnosis. (p. 7)


Medication error Any preventable adverse drug event involving inappropriate medication use by a patient or health care professional; it may or may not cause the patient harm. (p. 15)


Noncompliance An informed decision on the part of the patient not to adhere to or follow a therapeutic plan or suggestion. Use of noncompliance versus nonadherence in this textbook is supportive of the terms used in the current listing of NANDA-I nursing diagnoses. (p. 9)


Nursing process An organizational framework for the practice of nursing. It encompasses all steps taken by the nurse in caring for a patient: assessment, nursing diagnoses, planning (with goals and outcome criteria), implementation of the plan (with patient teaching), and evaluation. (p. 7)


Outcome criteria Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of goals related to each nursing diagnosis. These statements, as with goals, are verifiable, framed in behavioral terms, measurable, and time specific. Outcome criteria are considered to be specific, whereas goals are broad. (p. 7)


Prescriber Any health care professional licensed by the appropriate regulatory board to prescribe medications. (p. 8)


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http://evolve.elsevier.com/Lilley



Overview of the Nursing Process


The nursing process is a well-established, research-supported framework for professional nursing practice. It is a flexible, adaptable, and adjustable five-step process consisting of assessment, nursing diagnoses, planning (including establishment of goals and outcome criteria), implementation (including patient education), and evaluation. As such, the nursing process ensures the delivery of thorough, individualized, and quality nursing care to patients, regardless of age, gender, medical diagnosis, or setting. Through use of the nursing process combined with knowledge and skills, the professional nurse will be able to develop effective solutions to meet patient’s needs. The nursing process is usually discussed in nursing courses and/or textbooks that deal with the fundamentals of nursing practice, nursing theory, physical assessment, adult or pediatric nursing, and other nursing specialty areas. However, because of the importance of the nursing process in the care of patients, the process in all of its five phases is described in each chapter as it relates to specific drug groups or classifications.


Critical thinking is a major part of the nursing process and involves the use of the mind and thought processes to gather information and then develop conclusions, make decisions, draw inferences, and reflect upon all aspects of patient care. The elements of the nursing process address the physical, emotional, spiritual, sexual, financial, cultural, and cognitive aspects of a patient. Attention to these many aspects allows a more holistic approach to patient care. For example, a cardiologist may focus on cardiac functioning and pathology, a physical therapist on movement, and a chaplain on the spiritual aspects of patient care. However, it is the professional nurse who thinks critically about, processes, and incorporates all of these aspects and points of information about the patient and then uses this information to develop and coordinate patient care. Therefore, the nursing process remains a central process and framework for nursing care. Box 1-1 provides guidelines for nursing care planning related to drug therapy and the nursing process.



BOX 1-1


GUIDELINES FOR NURSING CARE PLANNING


This sample presents useful information for developing a nursing process– focused care plan for patients receiving medications. Brief listings and discussions of what must be contained in each phase of the nursing process are included. This sample may be used as a template for formatting nursing care plans in a variety of patient care situations/settings.


Assessment


Objective Data


Objective data include information available through the senses, such as what is seen, felt, heard, and smelled. Among the sources of data are the chart, laboratory test results, reports of diagnostic procedures, physical assessment, and examination findings. Examples of specific data are age, height, weight, allergies, medication profile, and health history.


Subjective Data


Subjective data include all spoken information shared by the patient, such as complaints, problems, or stated needs (e.g., patient complains of “dizziness, headache, vomiting, and feeling hot for 10 days”).


Nursing Diagnoses


Once the assessment phase has been completed, the nurse analyzes objective and subjective data about the patient and the drug and formulates nursing diagnoses. The following is an example of a nursing diagnosis statement: “Deficient knowledge related to lack of experience with medication regimen and second-grade reading level as an adult as evidenced by inability to perform a return demonstration and inability to state adverse effects to report to the prescriber.” This statement of the nursing diagnosis can be broken down into three parts, as follows:



• Part 1—“Deficient knowledge.” This is the statement of the human response of the patient to illness, injury, medications, or significant change. This can be an actual response, an increased risk, or an opportunity to improve the patient’s health status. The nursing diagnosis related to knowledge may be identified as either deficient or readiness for enhanced (knowledge).


• Part 2—“Related to lack of experience with medication regimen and second-grade reading level as an adult.” This portion of the statement identifies factors related to the response; it often includes multiple factors with some degree of connection between them. The nursing diagnosis statement does not necessarily claim that there is a cause-and-effect link between these factors and the response, only that there is a connection.


• Part 3—“As evidenced by inability to perform a return demonstration and inability to state adverse effects to report to the prescriber.” This statement lists clues, cues, evidence, and/or data that support the nurse’s claim that the nursing diagnosis is accurate.


Nursing diagnoses are prioritized in order of criticality based on patient needs or problems. The ABCs of care (airway, breathing, and circulation) are often used as a basis for prioritization. Prioritizing always begins with the most important, significant, or critical need of the patient. Nursing diagnoses that involve actual responses are always ranked above nursing diagnoses that involve only risks.


Planning: Goals and Outcome Criteria


The planning phase includes the identification of goals and outcome criteria, provides time frames, and is patient oriented. Goals are objective, realistic, and measurable patient-centered statements with time frames and are broad, whereas outcome criteria are more specific descriptions of patient goals.


Implementation


In the implementation phase, the nurse intervenes on behalf of the patient to address specific patient problems and needs. This is done through independent nursing actions; collaborative activities such as physical therapy, occupational therapy, and music therapy; and implementation of medical orders. Family, significant others, and caregivers assist in carrying out this phase of the nursing care plan. Specific interventions that relate to particular drugs (e.g., giving a particular cardiac drug only after monitoring the patient’s pulse and blood pressure), nonpharmacologic interventions that enhance the therapeutic effects of medications, and patient education are major components of the implementation phase. See the previous text discussion of the nursing process for more information on nursing interventions.


Evaluation


Evaluation is the part of the nursing process that includes monitoring whether patient goals and outcome criteria related to the nursing diagnoses are met. Monitoring includes observing for therapeutic effects of drug treatment as well as for adverse effects and toxicity. Many indicators are used to monitor these aspects of drug therapy as well as the results of appropriately related nonpharmacologic interventions. If the goals and outcome criteria are met, the nursing care plan may or may not be revised to include new nursing diagnoses; such changes are made only if appropriate. If goals and outcome criteria are not met, revisions are made to the entire nursing care plan with further evaluation.


Assessment


During the initial assessment phase of the nursing process, data are collected, reviewed, and analyzed. Performing a comprehensive assessment allows you to formulate a nursing diagnosis related to the patient’s needs—for the purposes of this textbook, specifically needs related to drug administration. Information about the patient may come from a variety of sources, including the patient; the patient’s family, caregiver, or significant other; and the patient’s chart. Methods of data collection include interviewing, direct and indirect questioning, observation, medical records review, head-to-toe physical examination, and a nursing assessment. Data are categorized into objective and subjective data. Objective data may be defined as any information gathered through the senses or that which is seen, heard, felt, or smelled. Objective data may also be obtained from a nursing physical assessment; nursing history; past and present medical history; results of laboratory tests, diagnostic studies, or procedures; measurement of vital signs, weight, and height; and medication profile. Medication profiles include, but are not limited to, the following information: any and all drug use; use of home or folk remedies and herbal and/or homeopathic treatments, plant or animal extracts, and dietary supplements; intake of alcohol, tobacco, and caffeine; current or past history of illegal drug use; use of over-the-counter (OTC) medications (e.g., aspirin, acetaminophen, vitamins, laxatives, cold preparations, sinus medications, antacids, acid reducers, antidiarrheals, minerals, elements); use of hormonal drugs (e.g., testosterone, estrogens, progestins, oral contraceptives); past and present health history and associated drug regimen(s); family history and racial, ethnic, and/or cultural attributes with attention to specific or different responses to medications as well as any unusual individual responses; and growth and developmental stage (e.g., Erikson’s developmental tasks) and issues related to the patient’s age and medication regimen. A holistic nursing assessment includes gathering of data about the whole individual, including physical/emotional realms, religious preference, health beliefs, sociocultural characteristics, race, ethnicity, lifestyle, stressors, socioeconomic status, educational level, motor skills, cognitive ability, support systems, lifestyle, and use of any alternative and complementary therapies. Subjective data include information shared through the spoken word by any reliable source, such as the patient, spouse, family member, significant other, and/or caregiver.


Assessment about the specific drug is also important and involves the collection of specific information about prescribed, OTC, and herbal/complementary/alternative therapeutic drug use, with attention to the drug’s action; signs and symptoms of allergic reaction; adverse effects; dosages and routes of administration; contraindications; drug incompatibilities; drug-drug, drug-food, and drug–laboratory test interactions; and toxicities and available antidotes. Nursing pharmacology textbooks provide a more nursing-specific knowledge base regarding drug therapy as related to the nursing process. Use of current references or those dated within the last 3 years is highly recommended. Some examples of authoritative sources include the Physicians’ Desk Reference, Mosby’s Drug Consult, drug manufacturers’ inserts, drug handbooks, and/or licensed pharmacists. Reliable online resources include, but are not limited to the U.S. Pharmacopeia (USP) (http://www.usp.org), U.S. Food and Drug Administration (http://www.fda.gov), and http://www.WebMD.com. Other online resources are cited throughout this textbook.


Gather additional data about the patient and a given drug by asking these simple questions: What is the patient’s oral intake? Tolerance of fluids? Swallowing ability for pills, tablets, capsules, and liquids? If there is difficulty swallowing, what is the degree of difficulty and are there solutions to the problem, such as use of thickening agents with fluids or use of other dosage forms? What are the results of laboratory and other diagnostic tests related to organ functioning and drug therapy? What do renal function studies (e.g., blood urea nitrogen level, serum creatinine level) show? What are the results of hepatic function tests (e.g., total protein level, serum levels of bilirubin, alkaline phosphatase, creatinine phosphokinase, other liver enzymes)? What are the patient’s white blood cell and red blood cell counts? Hemoglobin and hematocrit levels? Current as well as past health status and presence of illness? What are the patient’s experiences with use of any drug regimen? What has been the patient’s relationship with health care professionals and/or experiences with previous therapeutic regimens? What are current and past values for blood pressure, pulse rate, temperature, and respiratory rate? What medications is the patient currently taking, and how is the patient taking and tolerating them? Are there issues of compliance? Any use of folk medicines or folk remedies? What is the patient’s understanding of the medication? Are there any age-related concerns? If patients are not reliable historians, family members, significant others, and/or caregivers may provide answers to these questions.


It is worth mentioning that there is often discussion about the difference between the terms compliance and adherence. Both of these terms, though not to be used interchangeably, are used to describe the extent to which patients take medications as prescribed. Often the term adherence is perceived as implying more collaboration and active role between patients and their providers (see Key Terms definition of compliance). Once assessment of the patient and the drug has been completed, the specific prescription or medication order (from any prescriber) must be checked for the following six elements: (1) patient’s name, (2) date the drug order was written, (3) name of drug(s), (4) drug dosage amount and frequency, (5) route of administration, and (6) prescriber’s signature.


It is also important during assessment to consider the traditional, nontraditional, expanded, and collaborative roles of the nurse. Physicians and dentists are no longer the only practitioners legally able to prescribe and write medication orders. Nurse practitioners and physician assistants have gained the professional privilege of legally prescribing medications. Remain current on legal regulations as well as specific state nurse practice acts and standards of care.


Analysis of Data


Once data about the patient and drug have been collected and reviewed, critically analyze and synthesize the information. Verify all information and document appropriately, and it is at this point that the sum of the information about the patient and drug are used in the development of nursing diagnoses.



CASE STUDY


The Nursing Process and Pharmacology


image Dollie, a 27-year-old social worker, is visiting the clinic today for a physical examination. She states that she and her husband want to “start a family,” but she has not had a physical for several years. She was told when she was 22 years of age that she had “anemia” and was given iron tablets, but Dollie states that she has not taken them for years. She said she “felt better” and did not think she needed them. She denies any use of tobacco and illegal drugs; she states that she may have a drink with dinner once or twice a month. She uses tea tree oil on her face twice a day to reduce acne breakouts. She denies using any other drugs.



1. What other questions does the nurse need to ask during this assessment phase?


2. After laboratory work is performed, Dollie is told that she is slightly anemic. The prescriber recommends that she resume taking iron supplements as well as folic acid. She is willing to try again and says that she is “all about doing what’s right to stay healthy and become a mother.” What nursing diagnoses would be appropriate at this time?


3. Dollie is given a prescription that reads as follows: “Ferrous sulfate 325 mg, PO for anemia.” When she goes to the pharmacy, the pharmacist tells her that the prescription is incomplete. What is missing? What should be done?


4. After 4 weeks, Dollie’s latest laboratory results indicate that she still has anemia. However, Dollie states, “I feel so much better that I’m planning to stop taking the iron tablets. I hate to take medicine.” How should the nurse handle this?


For answers, see http://evolve.elsevier.com/Lilley.


Nursing Diagnoses


Nursing diagnoses are developed by professional nurses and are used as a means of communicating and sharing information about the patient and the patient experience. Nursing diagnoses are the result of critical thinking, creativity, and accurate collection of data regarding the patient as well as the drug. Nursing diagnoses related to drug therapy will most likely grow out of data associated with the following: deficient knowledge; risk for injury; noncompliance; and various disturbances, deficits, excesses, impairments in bodily functions, and/or other problems or concerns as related to drug therapy. The development and classification of nursing diagnoses has been carried out by the North American Nursing Diagnosis Association International (NANDA-I) (formerly NANDA). NANDA-I is the formal organization recognized by professional nursing groups (e.g., the American Nurses Association [ANA]). NANDA-I is considered to be the major contributor to the development of nursing knowledge and the leading authority (on nursing diagnoses). The purpose of NANDA-I is to increase the visibility of nursing’s contribution to the care of patients and to further develop, refine, and classify the information and phenomena related to nurses and professional nursing practice. In 2000, a classification system was adopted with a taxonomy including 13 domains divided into 106 classes and over 150 nursing diagnoses. Using this system, the nurse was able to choose a nursing diagnosis from the established list and individualize the nursing care plan. The 2009-2011 NANDA approved nursing diagnoses included many changes with revisions, as well as several new diagnoses and a listing of retired nursing diagnoses. The newest list, 2012-2014 NANDA-I approved nursing diagnoses, are still characterized with domains and classes but also with changes that include several new and revised nursing diagnoses or diagnoses with a key word changed. See Box 1-2 for more information about the 2012-2014 NANDA approved nursing diagnoses.



BOX 1-2


A BRIEF LOOK AT NANDA AND THE NURSING PROCESS


The North American Nursing Diagnosis Association International (NANDA-I) (formerly NANDA) fulfills the following roles: (1) increases the visibility of nursing’s contribution to patient care, (2) develops, refines, and classifies information and phenomena related to professional nursing practice, (3) provides a working organization for the development of evidence-based nursing diagnoses, and (4) supports the improvement of quality nursing care through evidence-based practice and access to a global network of professional nurses. In 1987, NANDA and the American Nurses Association endorsed a framework for establishing nursing diagnoses, and in 1990 Nursing Diagnoses became the official journal of NANDA. In 2001 and 2003, NANDA modified and updated the listing of nursing diagnoses, but nursing diagnoses continued to be submitted for consideration by the Ad Hoc Research Committee of NANDA. This period resulted in changes such as replacement of the phrase potential for with risk for. The terms impaired, deficient, ineffective, decreased, increased, and imbalanced replaced the outdated terms altered and alteration, although the outdated terms may still be in use. In 2002, NANDA changed its name to NANDA-I (“I” for international) to reflect the organization’s global reach. In 2007-2008, there were 188 nursing diagnoses (up from 172) with changes to defining characteristics and related or risk factors. There were also some 15 newly approved nursing diagnoses. More changes occurred in the 2009-2011 version of NANDA-I’s Nursing Diagnoses: Definitions and Classifications, with 21 new, 9 revised, and 6 retired nursing diagnoses. Most current is the 2012-2014 NANDA-I Approved Nursing Diagnoses. There are 23 new, 33 revised, and 2 retired nursing diagnoses. Other changes are discussed in the 2012-2014 NANDA-I Nursing Diagnoses: Definitions and Classifications.

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May 9, 2017 | Posted by in NURSING | Comments Off on The Nursing Process and Drug Therapy

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