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Applying the Nursing Process to Drug Therapy Role of the RN in Medication Assessment & Administration.

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Presentation on theme: "Applying the Nursing Process to Drug Therapy Role of the RN in Medication Assessment & Administration."— Presentation transcript:

1 Applying the Nursing Process to Drug Therapy Role of the RN in Medication Assessment & Administration

2 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

3 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)

4 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

5 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.

6 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

7 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

8 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

9 Researching the medication ordered Use current text/handbook Review: classification, mechanism of action doses, routes, side effects, contraindications, drug incompatibilities interactions, precautions & nursing implications

10 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

11 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!!

12 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

13 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

14 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

15 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!!

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