Presentation on theme: "Applying the Nursing Process to Drug Therapy Role of the RN in Medication Assessment & Administration."— Presentation transcript:
Applying the Nursing Process to Drug Therapy Role of the RN in Medication Assessment & Administration
Assessment of Client Collect Subjective & Objective data: Client, Drug & Environment Use current Drug handbook/text reference/ licensed pharmacist Complete a drug history Perform a Nursing Physical Assessment Create a medication profile
Assessing Drug History of Client OTC meds (e.g. aspirin, vitamins, dietary supplements, NSAIDS, laxatives, dietary supplements, antacids, minerals, elements) Prescription Medications (e.g. birth control pills, hormone replacements, drugs for sexual dysfunction) Street drugs (e.g. marijuana, cocaine, PCP, LSD, illegal narcotics i e. oxycontin)
Drug History (continued) Herbals & homeopathic substances Problems with drug therapy in the past (e.g., allergies, adverse effects, diseases or injuries, organ pathology) Growth & development issues as related to the client’s age and specific expectations( e.g. Erickson's stages of development) and task for each major group
The Interview Process Establish a therapeutic relationship with client Use open ended questions (avoid “yes” or “No” answers) Questions/content of questions should include: Oral intake of client: how does client tolerate fluids swallow problems Laboratory/diagnostic test value e.g. renal, liver panels, hgb/hct., protein, albumin levels.
Interview process/Med eval Consider client’s experience with meds/health care system, previous hosp. Check vital signs (establish baseline) List meds client is taking /how taken/when List new meds ordered Use holistic framework- identify emotional, physical, cognitive, cultural & socioeconomic factors impacting drug therapy & nursing process
Interview Process/med eval (cont.) Check drugs adverse effects & contraindications, routes of administration, toxicity, therapeutic levels Drug action Are there any “age specific” developmental concerns How does the cultural origin & racial/ethnic group of client influence the drug therapy
Medication Orders Orders must contain six elements: Client’s name Date & time order was written Name of the medication Dosage (includes size, frequency & number of doses) Route of delivery Signature of prescriber
Researching the medication ordered Use current text/handbook Review: classification, mechanism of action doses, routes, side effects, contraindications, drug incompatibilities interactions, precautions & nursing implications
Analysis of Date: developing a nursing diagnosis Base diagnosis on conclusion about risk factors, actual client needs or problems based on knowledge base. E.g. nursing diagnosis include: Deficient knowledge; risk for injury; noncompliance Diagnosis based on s/e or risk factors e.g.:. fatigue, constipation, impaired tissue perfusion, sexual dysfunction, sleep disturbance, urinary retention
Planning care: identifying goals & outcome criteria Prioritize the nursing diagnosis Specify objective, measurable, realistic goals Establish a time period for achievement of outcomes If order is in question- do not give- call physician for clarification/further instructions. Document all information obtained!!
Implementation Requires constant communication& collaboration with client& health care team Follow the “six rights”: Right drug Right dose Right time Right route Right client Right documentation
Client/patient’s rights with regards to medication Right to a “double check” Right to proper storage/documentation Right to accurate calculation& preparation Right to careful checking of transcription of orders Client safety- use of correct administration procedures Right to accurate routes of administration
Client/patient rights –cont’d Right to close consideration of special situations e.g.: difficulty with swallowing, client with NG tube or who is unconscious Right to having all measures taken to prevent and report med errors if they occur Right to individualized /complete client teaching Right of accurate/cautious monitoring Right to accurate documentation
Evaluation of drug therapy: an ongoing part of the nursing process Monitor client responses to the drug Monitor expected and unexpected responses Monitor therapeutic (intended effects), side effects, adverse effects & toxic effects Document !! Very important!!