The role of the nurse in drug therapy

Chapter 3 The role of the nurse in drug therapy



CHAPTER CONTENTS


Introduction 29

The role of the nurse in drug therapy 29
Requisites for the role 29

The role of the nurse (in summary) 32

Assessing patients and their medicines 33

Planning drug therapy 34

Interpreting the prescription 34

Minimising cross-infection 35

Checking the product 35

Calculating the dose to be given 36

Identifying the patient 36

Positioning the patient 36

Selecting, checking and administering the medicine 36

Using professional judgement 37

Teaching the patient 38

Promoting the effectiveness of medicines 38

Monitoring the effect of medicines 38

Maintaining the comfort of the patient 40

Disposal of time-expired and unwanted medicines 40

Keeping records 40

Evaluating and reporting back 41

The role of the nurse in primary care 41
The community nurse 41

The practice nurse 43

The community midwife 44

Specialised drug therapy in the home 44

Self-assessment questions 45


KEY OBJECTIVES


After reading this chapter, you should be able to:


• identify the key elements of the role of the nurse in drug therapy

• assess, plan, implement and evaluate prescribed drug therapy

• name appropriate reference sources to assist in the administration of medicines

• summarise the role of the nurse in primary care in relation to drug therapy.


INTRODUCTION


From the earliest days of their career, all nurses are involved to some extent in the management of medicines. Although responsibilities increase and change with time, the safe and effective management of medicines remains a high priority for all practising nurses. The importance of establishing a firm basis of learning during preregistration training is well recognised, as is the need to progress to wider aspects as part of professional development. Thus, nurses build on the knowledge and skills acquired to prepare themselves for the particular responsibilities and duties in their chosen speciality. As with all health professionals, nurses have a responsibility to keep up to date and to make their contribution to professional issues of the day.



THE ROLE OF THE NURSE IN DRUG THERAPY



REQUISITES FOR THE ROLE



PHARMACOLOGY AND PHYSIOLOGY


To be safe in the administration of medicines and to be able to advise patients appropriately, the nurse requires an understanding of basic pharmacology, which includes:


• drug absorption mechanisms (see p. 125)

• the metabolic action of the liver (see p. 128)

• the method by which substances are transported in the bloodstream (see p. 126)

• the excretory function of the kidneys (see also Ch. 18).

Without an appreciation of the relevant physiology, a nurse’s understanding of how drugs act in the body is incomplete, and therefore safety and effectiveness in practice is open to question. A lack of specialist knowledge of the physiology of extremes of age may hazard the very young or very old patient, who is often more at risk from adverse drug reactions than patients in other age groups.


In a study by King (2004), one group of nurses identified the need for more pharmacology knowledge in practice. It claimed that improved pharmacology teaching might increase nurses’ confidence in performing drug administration, patient education and nurse prescribing.



LEGAL AND PROFESSIONAL RESPONSIBILITIES


The standards expected of each individual registered nurse, midwife and health visitor with respect to medicines are made explicit by the Nursing and Midwifery Council (2004a). To meet such standards, the expectation is that nurses are personally accountable for their practice and, in so doing, act at all times to promote and safeguard the interests and well-being of patients and clients. This requirement applies to all persons on the Council’s register, irrespective of the part on which their name appears.


Each health authority is required to establish policies and procedures that set out in detail instruction and guidance on the administration and storage of medicines. These policies are derived from statutory sources and government health circulars of guidance issued by the Department of Health. Local policies that relate to a functional unit such as a hospital or ward may also exist within this wider context. Copies of relevant policies should be readily accessible. It is incumbent on nurses to become fully conversant with them and to adhere to them at all times.


The clauses of the Code of Professional Conduct apply as much to the management of medicines as to any other aspect of nursing practice. The major tenets of the Code are:


• respect for patient/client

• consent for treatment/care

• cooperation with others in the team

• protection of patient confidentiality

• maintenance of professional knowledge and competence

• trustworthiness

• minimisation of risk (Nursing and Midwifery Council 2004a).


ETHICAL ISSUES


A range of ethical issues arise which are associated with the management of medicines and with which the nurse should be familiar. They are mentioned here for completeness but offer no right or wrong answers, because there are none. Indeed, there are probably even more questions raised than are answered. They are also included in the relevant chapter, although a detailed discussion of each is beyond the scope of this book.


Much discussion takes place over the allocation of resources. Monies ring-fenced for active treatment, or for care for those who will not get better and are entitled to maximum quality of life, may be better spent on prevention of disease. A hot topic is ‘postcode prescribing’, in which treatment is available in one part of the country but not in another. Such a situation flies in the face of the ethos of the NHS, in which the intention is to provide equality of care for all at the point of delivery.


The question arises of withholding treatment from those who persist with unhealthy disease-forming habits. The human rights lobby for individual free-doms arises with such issues as the right to refuse treatment, euthanasia and the beliefs of faith groups. Consideration of the staff’s rights must also be included in any discussion and include topics such as the right not to participate in termination of pregnancy (Conscience Clause, Abortion Act 1967, 1990) and also their right to withdraw from the care of someone to whom they are related or know as a neighbour or friend. Nurses’ rights will be meaningful to them, although it should be remembered that those left to carry on with the duties may not approve or be sympathetic. All healthcare personnel, whatever their individual standpoint, have a duty of care.


In the event of an error, greater respect will be granted to the nurse who owns up rather than conceals it. Although every effort must be made to minimise them, errors will always occur and in their own way provide opportunities for learning (see p. 104).


There may also be the rare occasion when nurses witness an incident or practice that they believe is unprofessional and their conscience tells them that it is the time to ‘whistle blow’. Full investigation by the nurse manager will be required.



THE MEDICINES


A working knowledge of medicines in common use should be developed, which includes:


• range of presentation of medicines

• ordering/requisitioning procedures

• storage of medicines and disposal of unwanted medicines

• legislation and health authority policies

• prescribing/recording procedures

• dosage levels

• routes/methods of administration

• rationale for the particular therapy

• safe handling of drugs known to be hazardous

• methods of promoting effectiveness of and/or reducing the need for drug therapy.

A bank of knowledge/understanding of the following aspects should be acquired on a continual basis:


• mode of action of drugs

• recognition of side effects and methods of minimising/dealing with unavoidable side effects

• signs and symptoms of drug toxicity

• methods of dealing with effects of drug toxicity

• drug–drug interactions

• drug–food interactions

• effects of disease states on drug therapy

• potential dangers of self-medication

• use of clinical reagents

• use of drugs in diagnostic tests

• aspects of research into drugs

• methods of achieving/improving patient concordance.

Acquiring and using knowledge contribute to safety in the administration of medicines, and by understanding the theory behind the administration of medicines nurses can act with confidence. In the exercise of professional accountability, however, nurses must be prepared to acknowledge any limitations to their knowledge or practice. It is important, too, to recognise that information about medicines and their management keeps changing, and that practising nurses have a responsibility to keep pace with new developments. Up-to-date knowledge, of course, is not in itself sufficient to guarantee safe practice.



OBSERVATION


By continual observation, a nurse assesses the patient’s condition before and after drug treatment and, in so doing, helps to establish when treatment is indicated and whether it is being beneficial or otherwise. Nurses routinely measure and record indices such as blood pressure, pulse rate and weight, but it is the ability to note (and report) significant changes in these recordings that is important.


Observable changes in a patient receiving specific forms of drug therapy may include:


• allergic reaction, ranging from skin rash to anaphylaxis

• muscular weakness arising from potassium loss in diuretic therapy

• bruising or overt bleeding arising from too high a dose of an anticoagulant

• euphoria associated with corticosteroid therapy

• depression associated with antihypertensive drug therapy

• anorexia in patients receiving digoxin therapy

• breakdown of oral mucosa in patients receiving cytotoxic drugs

• signs of hypoglycaemia in a patient who has received insulin without adequate food.


COMMUNICATION


From the moment people become patients, their continued well-being (and eventual restoration to health) depends on effective communication between nurse and patient and among healthcare personnel. Nowhere is this more important than with all aspects of drug therapy.


If patients are unable to communicate, information about a medical condition and/or drug therapy may be found on a medical pendant or bracelet, or on a medication card on their person.


An equally important part of the communication process is a willingness to listen. Patients are often happy to talk about their illnesses and treatments, and by appropriate questioning and astute follow-up of cues, it is possible to assess how much patients understand their disorder and which problems are most real to them. A patient’s gesture, facial expression or mood can convey, respectively, the nature or location of pain, the like or dislike of taking a medicine, and the likelihood of taking the medicines.


Particular opportunities for communication between nurse and patient arise at the time that medicines are being administered. For example, when applying a preparation to an area of broken skin, the nurse may help to ease pain by engaging the patient in some topic of conversation so as to divert attention from the procedure. It is not always appropriate, however, to deal with detailed questions at the time of administration, as this may cause too much delay or increase the risk of error in the procedure itself. Nevertheless, patients are entitled to know:


• the name of the medicine

• why it is being given

• the dose they are to have

• how often it is to be taken

• if known, the length of the course of treatment

• any likely side effects, as appropriate.

If questions cannot be dealt with fully at the time of administration, patients should be assured that a more detailed explanation will be given later. Patients may need additional explanation and reassurance when a new treatment is to be begun or when a medicine is changed or discontinued. If requested or considered desirable, a family member should be included in discussions. Wherever possible, instructions should be provided in written form.


The nurse should also be willing to learn from the patient (see Ch. 7). Many patients, especially those suffering from chronic conditions such as dermatological conditions, asthma, myasthenia gravis or Parkinson’s disease, will almost certainly have far more practical experience than the nurse in managing their condition. For example, such patients are likely to know, by personal experience, the optimum time for administration of their medicine.



PRACTICAL SKILLS


Apart from the situations in which patients manage their own drug therapy, medicines are administered by nurses using skills acquired through learning and practice. Improvements in drug presentation, such as prefilled syringes and aseptic dispensing services, continue to assist the safety of drug administration. Application of modern technology in clinical areas and the development of certain procedures hitherto carried out by doctors, however, have placed additional demands on nurses’ skills and technical abilities. The use of electronically controlled drug delivery systems, pumps and other devices requires quite different skills from those traditionally associated with nursing. Against this background, it is important that the traditional practical skills of the nurse are not neglected.


The degree of skill required in the administration of medicines varies considerably depending on the dosage form used, the route/method of administration, and the extent to which the patient cooperates or is able to cooperate. For example:


• the giving of a tablet to a relatively well, intelligent and cooperative adult presents few problems

• administering a small volume of a liquid medicine from a dropper to a severely disabled child presents a greater challenge

• to succeed in administering an intramuscular injection to a very agitated and uncooperative patient demands experience, skill and tenacity.

The motor skills required include manual dexterity and coordination of hand and eye, coupled with lightness and delicacy of touch. Specialised situations, such as those met with in dermatology and ophthalmology, call for skills acquired only through repeated practice.



COMMITMENT


The least tangible part of the nursing role is the nurse’s overall attitude to patients and the management of their medicines. Relevant skills and knowledge are vital if nurses are to discharge their basic responsibilities. However, without an informed respect for drugs generally, the full benefits of drug therapy will not be achieved and drug therapy may fail.


On a professional level, the nurse should have an awareness of the place of all medicines in the care of the patient. It is vital to recognise the reasons for the need to be systematic in adherence to both national (legal) and local standards. This recognition should be based on a broad understanding of the principles involved and not merely the mechanical following of a set of rules. An overall sense of the need for security in its widest sense is required, coupled with an appreciation of economic factors. An enquiring attitude of mind, associated with a knowledgeable, well-informed approach, will give the nurse confidence to play a full part in ensuring safe and effective drug therapy.


It is also important to consider those attitudes that are, to a large extent, linked with personal qualities. These include powers of observation and the ability to keep calm and work under pressure. Being selective in dealing with interruptions during procedures involving medicines calls for judgement, patience and occasionally a sense of humour. The nurse must exercise judgement, because a degree of flexibility may be called for on occasion; firmness, linked with tact, is a prerequisite. The balanced assessment of one’s own knowledge, or lack of it, is important, as is the willingness to ask and seek advice.


Nurses have a duty to encourage patients (without causing anxiety) to regard all medicines with respect. In exercising the necessary skills and demonstrating the correct attitude, nurses set an example for patients to follow. Special emphasis on certain aspects, such as the need for safe storage of medicines, can be reinforced by the attitude adopted by nurses and the care and concern they show. A patient may be reluctant to take the medicines and/or unable to see the need for them. This demands patience and perseverance by the nurse. Often, the problem arises with those in greatest need of the treatment. With a responsibility to act as a role model in health education, the nurse should respect medicines at all times, on both a professional and a personal level.



THE ROLE OF THE NURSE (IN SUMMARY)


Although it is recognised that the emphasis will vary depending on the speciality in which the nurse works, the role of the nurse in drug therapy can be broadly summarised under the following headings:


• to ensure that the correct dosage is given at the correct time and by the correct route, observing any special requirements

• to observe/report any side effects and consequences of drug interactions

• to take action to alleviate unavoidable side effects

• to observe and assess the patient so that medical and nursing decisions can be made

• to participate in education and guidance of patients (and in some cases their relatives) with regard to their drug therapy

• to take action to promote patient compliance and the achievement of therapeutic objectives

• to provide nursing care to help reduce, or obviate, the need for drug therapy

• to follow recognised procedures for the control of medicines and pharmaceutical products

• to contribute to the evaluation, research and development of new treatments, and/or the reassessment of existing treatments

• to contribute to the development of medicine management in a changing environment.

The discharge of every aspect of the nurse’s role in drug therapy is essential for the well-being of the patient.


Many changes and developments continue to take place within healthcare and the health professions. A number of them are having, and will continue to have, an increasing impact on the practising nurse, whether in hospital or community. Some of the areas of significant development are as follows:


• provision of healthcare in the primary care sector

• complexity of drug therapy in both hospitals and the community

• specialisation in the use of drugs

• new drug delivery systems

• drug presentation, packaging and drug distribution systems

• side effects of drug treatment

• interest in alternative medicine

• the need to use resources effectively

• the need to ensure that whoever is administering the drugs is not harmed by them

• the need to ensure the safe and effective use of medicines by older people

• the use of computers in clinical practice, both in hospitals and in the community

• self-care

• access by the general public to technological information about medical conditions and their treatment

• clinical pharmacy services

• reduction in junior hospital doctors’ hours and changes in GPs’ contract

• professional aspirations of healthcare workers.

The practising nurse cannot fail to be aware of the great benefits as well as the potential dangers of drug therapy. As nurses are accountable for their clinical actions, it is essential that well-founded confidence is acquired in whatever is undertaken. This confidence is achieved through the acquisition of practical skills supported by the necessary theoretical knowledge. No matter how careful and expert the prescriber or dispensing pharmacist, the consequences for patients may be disastrous if nurses are ill equipped to discharge their vital role to the full.


The nurse’s role is much more than a mechanical achievement of objectives. It is a professional role requiring knowledge, skills, judgement and commitment.



ASSESSING PATIENTS AND THEIR MEDICINES


Whether the patient has been newly referred to the community nurse or has been admitted to hospital, it is essential that the nurse is aware of the relevant details of the person who is to receive the medication. In hospital, the patient’s name, date of birth and unit number are required to correctly identify the patient. Understanding patients’ medical diagnoses and awareness of their physical capabilities and mental capacity are essential in achieving safe and effective drug treatment. Dietary, cultural and economic influences should also be noted, as well as availability of family support.


Patients should be asked if they are taking medicines of any kind – prescribed or non-prescribed – and whether they are experiencing any difficulty with them. The patient may reveal a belief in alternative medicine or some form of lay medicine, and this should never be discounted. The effect that individual drugs are having, or may be suspected of having, on the activities of living should be considered. For example:


• the constipating effect of some analgesics may affect elimination

• the nauseating effect of an antibiotic may interfere with eating and drinking

• a sedative drug may make communication difficult.

An examination of medicines brought into hospital by the patient may reveal patient non-compliance. Through observation and/or questioning, the nurse may be the first to discover that the patient is hyper-sensitive to a medicine.



PLANNING DRUG THERAPY


Medicines are prescribed by those qualified to do so, taking into account the patient’s age and other factors including body mass, physical and mental condition, concurrent illness and, in some instances, the patient’s specific requests or beliefs. The nurse can assist in suggesting times of administration that will fit in with other activities in which the patient is involved. When the presentation of the medicine (e.g. a large tablet) is likely to pose a problem, the nurse can draw the prescriber’s attention to the patient’s difficulty. In this situation, the clinical pharmacist can be of particular assistance. When an intravenous infusion is to be begun, it may be possible to take into account the patient’s preference of arm to use. Here, the nurse can act as the patient’s advocate. With the expanding role of the nurse in hospital and community, including the increasing introduction of nurse-led units, nurses are in an excellent position to represent their patients and speak up on their behalf regarding their medication requirements.



INTERPRETING THE PRESCRIPTION


Responsibility rests with the prescriber to provide the statutory components of a prescription, clearly and indelibly written or computer-generated, authorising the administration of any medicine(s) irrespective of whether the prescriber or another person is going to administer the medicine(s). Unless provided for in a specific protocol, or in very exceptional circumstances, instruction by telephone to administer a previously unprescribed substance is not acceptable (Royal Pharmaceutical Society of Great Britain 2005). On occasion, in community hospitals, there may be no alternative to a prescription being ordered by telephone. In such cases, locally agreed procedures should be followed. A registered nurse, in all situations, must take the message, repeating it to the doctor to ensure accuracy. Where possible, a second nurse should also take the message, again repeating it to the doctor to ensure accuracy. An entry should be made by the nurse(s) taking the message on the appropriate prescription sheet. The prescribing doctor should sign the entry at the earliest possible opportunity. Local policy will demand that, in any event, the prescription is signed within a set period of time, for example 24 h (Nursing and Midwifery Council 2004b). New prescriptions for controlled drugs (CDs) must never be ordered by telephone.


An alternative to telephoning prescriptions is using facsimile transmission (fax). Computerised prescribing systems are being developed for use in hospitals. In primary care, most GPs use computers for both acute and repeat prescribing. Whatever the method used, where the new prescription replaces an earlier one the latter must be clearly cancelled and the cancellation signed and dated by a registered practitioner.


Transcribing is the substitution by a registrant of the Nursing and Midwifery Council of an original order written by an independent prescriber (Nursing and Midwifery Council 2003). The Nursing and Midwifery Council states that there is no legal barrier to transcribing. Registrants, however, because there is considerable room for error and they are accountable for their actions, are strongly advised to check on local policy in such instances.


All prescriptions must bear:


• the full name of the patient

• the patient’s address if at home or, in the case of an in-patient, the hospital and ward

• the patient’s age/date of birth and unit number.

Six items must be present as part of the actual prescription before administration can take place.


1. The date (including day, month and year) of prescribing of each individual medicine, which should be coincidental with the date of commencement. As far as possible, medicines should not be prescribed prospectively, although it is recognised that, for practical purposes, preoperative medicines and diagnostic agents may have to be prescribed in this way.

Related posts:

  1. Adverse drug reactions and drug interactions
  2. Drug treatment of musculoskeletal and joint diseases
  3. Pharmacokinetics and pharmacodynamics
  4. Drug treatment of infections

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May 13, 2017 | Posted by in NURSING | Comments Off on The role of the nurse in drug therapy

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