Nurses have a significant role in the management and delivery of safe drug therapy. Influences on this role include technology, increased longevity of populations in general, and survival of persons with multiple and varied biopsychosocial needs. Variables in drug therapy are numerous and, at times, unknown. The nurse is most often the one person who follows the patient most closely and the one who is first to assess the patient’s response to drugs. The nurse applies knowledge of pharmacology to anticipate drug responses in the individual patient.

This chapter explores the use of the nursing process as it relates to drug therapy and patient education about pharmacotherapy. Careful attention to each phase of the process fosters the patient’s success with the prescribed medication regimen. Initiatives such as Quality and Safety Education for Nurses (QSEN) and the Guiding Principles for Patient Engagement are resources to help nurses ensure and advocate for patient-centered collaborative care.

The overall goal through all phases of QSEN is to prepare future nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of the health care systems in which they work.

The QSEN competencies are as follows:

1. Patient- and family-centered care: Recognize the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs.

2. Collaboration and teamwork: Function effectively in nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

3. Evidence-based practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

4. Quality improvement: Continuously improve the quality and safety of health care systems by using data to monitor outcomes of care processes and improvement methods to design and test changes.

5. Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

6. Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

This chapter focuses on patient- and family-centered care, and Chapter 12 offers additional information on safety in pharmacotherapy. QSEN competencies are also integrated throughout the book and are highlighted in special features such as Safety: Preventing Medication Errors boxes and High-Alert Drug icons. Patient-centered collaborative care is demonstrated in each nursing process.

Guiding Principles for Patient Engagement are core principles to support health care providers in their practice of patient-centered, quality care. These principles were developed by the Alliance for Quality Care (NAQC) and supported by the Robert Wood Johnson Foundation with the aim of “patient relationship as the cornerstone of patient safety and quality.”

The core principles address the dynamic partnership among patients, their families, and the providers of their health care, confidentiality, mutual responsibilities and accountabilities, levels of engagement, advocacy, respecting boundaries, appreciation of patient’s rights, mutuality, and health care literacy, and acknowledgment and appreciation of diverse backgrounds.

Both QSEN and the Guiding Principles for Patient Engagement assert principles that are foundational to patient-centered practice and safety in pharmacotherapy.

Nursing Process: Patient-Centered Collaborative Care

The phases of the nursing process are assessment, nursing diagnosis, planning, implementation (nursing interventions), and evaluation. Each phase is dependent on the preceding phase; sometimes revisiting a preceding phase is required. The phases are discussed as each relates to health teaching in drug therapy.

Assessment

The assessment phase of the nursing process is characterized by the systematic validation and documentation of information. Assessments are made throughout the nursing process. Assessment is particularly important because the data provided by the assessment form the basis on which nursing diagnoses are made and care is planned, implemented, and evaluated. Data collection must include both subjective and objective information.

Subjective Data

Subjective data are symptoms described by and apparent to the patient. The following components are reflective of subjective data related to the medication regimen:

• Current health history, including any problems with swallowing

• Patient symptoms

• Current medications, including over-the-counter (OTC) drugs, herbal remedies, and nutritional supplements

Dosage, frequency, and route of all drugs, and prescribing health care provider, if any

Patient knowledge about drug, its side effects, and reason drug is taken

Patient adherence with regimen and reasons for deviations (Were prescriptions filled and finished? Are deviations based on valid data/rationale and clinically sound?)

Patient expectation and perception of drug effectiveness

Patient knowledge about what effects or drug reactions to report to health care provider

Drug allergies or reactions both past and present; also reactions to food and dye

Use of tobacco products, alcohol, caffeine, and recreational drugs, including frequency and duration of use

• Past health history

Past illnesses, major injuries, drug therapy

Mental status

Medications saved from previous use, reason for saving them, and expiration date

• Patient’s environment

Home safety (stairs, lighting, rugs, smoke detectors, supplies) and neighborhood safety (lighting, sidewalks) to meet patient’s and family’s specific needs.

Patient’s language and communication needs (including language of origin)

Patient’s ability and readiness to read and follow instructions from the health care provider and the pharmacy

Patient knowledge of specific drug storage requirements, if any

Availability, willingness, and psychomotor ability to administer or assist in the administration of medications; capability for activities of daily living (This information is essential for third-party payment for continued home visits or for admission to an extended care facility.)

Household members (neighbors and friends and their roles, if possible); ages of household members

Learning style preferences

Readiness to learn

Dietary patterns, cultural and economic influences, safety

Financial resources or limitations (drugs can be expensive)

Remember: Patients, even those who do not intend to withhold information, do not always share everything about their medications. Therefore, in addition to asking about prescription drugs, ask specifically about vitamin and mineral supplements, herbal supplements, all contraceptives, and OTC drugs. Identify caffeine and nicotine use, and include questions about use of skin patches; laypersons often fail to see patches as a mechanism of drug administration. Home health nurses should ask to see the contents of the medicine chest at home (or other storage area for medications) and should ask if the patient practices pill-splitting as a cost-saving measure and whether a pharmacist is consulted. Based on the response, appropriate teaching can be initiated.

Objective Data

Objective data are signs that are measured and detected by another person. The following components are reflective of objective data related to the medication regimen:

• Physical health assessment: Limitations in gross- and fine-motor control; hand and joint range of motion; hand and finger muscle strength; visual impairment; and ability to read labels and correctly measure dosages.

• Laboratory test results and diagnostic studies: Baseline data are essential for future comparisons.

Data collection should provide additional information about the patient’s symptoms and should also target those organs most likely to be affected by drug therapy. For example, if a drug is nephrotoxic, the patient’s creatinine clearance should be assessed. Assess major body systems for any signs of reaction to or interaction of drugs or ineffectiveness of therapy.

Based on assessment data, the nurse must identify high-risk patients (those likely to have adverse reactions). The patient’s health history, physical assessment, and laboratory test results are sources of these data.

Enhancing patient adherence with the drug therapy regimen is an essential component of health teaching. The patient and family response to the following three questions provides the nurse with critical information unique to each patient’s teaching situation: