INTRODUCTION TO NURSING

PHARMACOLOGY

3. The Nursing Process

in Drug Therapy
 Learning Objectives:
• Upon completion of this chapter, you will be able to:
1. List the responsibilities of the nurse in drug therapy
2 Explain what is involved in each step of the nursing
process as it relates to drug therapy
3. Describe key points that must be incorporated in the
assessment of a patient receiving drug theraphy
4. Describe the essential elements of a medication order
5. Outline the important points that must be assessed and
considered before administering a drug combining
knowledge about the drug with knowledge of the patient
and the environment
6. Describe the role of the nurse and the patient in
preventing medication errors
Nursing: Art and Science
• Nursing is a unique and complex
science, as well as a nurturing and
caring art. In the traditional sense,
nursing has
• been viewed as ministering to and
soothing the sick. In the current
state of medical changes, nursing
also has become increasingly
technical and scientific. Nurses are
assuming increasing
responsibilities that involve not
only nurturing and caring but also
assessing, diagnosing, and
intervening with patients to treat,
to prevent, and to educate as they
assist patients in coping with
various health states.
 The Nursing Process

• Nurses use the nursing

process-a decision-
problem-solving process-
to provide efficient and
effective care.
• The process that defines
the practice of nursing,
most do include certain
key elements: assessment,
nursing diagnosis,
planning, implementation,
and evaluation.
 Nursing process
• A decision-making, problem-solving process—to provide
efficient and effective care.
• Is an ongoing, cyclic process that must respond to the
changing requirement of the patient.
• It is the foundation for the clinical practice of nursing.
• It provides the framework for consistent nursing actions,
using a problem solving approach rather than an intuitive
approach.
• When implemented properly, the nursing process provides a
method to evaluate the outcomes of the therapy delivered.
 What Is the focus of all nursing
care?
• To help individuals maximize their potential for maintaining the
highest possible level of independence in meeting self-care needs.
5 STEP MODEL
1. A- Assessment
2. D- nursing Diagnosis
3. P- Planning
4. I- Implementation
5. E- Evaluation
NOTE: Application of the nursing process with drug therapy ensures
that the patient receives the best, safest, most efficient, scientifically
based, holistic care.
B1. Assessment

It is the first step of the nursing process. This

involves systematic, organized collection of data
about the patient. Because the nurse is
responsible for holistic care, data must include
information about physical, intellectual,
emotional, social, cultural, and environmental
factors. When viewed together, this information
provides the nurse with the facts needed to plan
educational and discharge programs, arrange for
appropriate consultations, and monitor the
physical response to treatment or to disease.
 Assessment
- Gathering information.
- Identify the patient’s strengths and problem areas
- This involves systematic, organized collection of data about the
patient.
- Should continue to focus not only on the evolving changes in the
presenting symptoms and problems but also on the detection of
potential complications that may occur.
- Is an ongoing process that starts with the admission of the patient and
continues until the patient is discharged from care.
- It is the problem identifying phase of the nursing process.
a. Identify the patient’s strengths and problem areas based on defining
characteristics (ei. Signs and symptoms, and clinical evidence)
b. Initiate focused nursing assessment. The initial assessment must be
performed by a registered nurse who has the necessary assessment
skills to complete the physical examination and the knowledge base to
analyze the data assembled.
c. Identify risk factors that cause an individual or group of people to be
more vulnerable to the development of certain problems in response to
a disease process or to the prescribed therapeutic interventions when
used. (ei. Side effects to drugs that may require modification of the
regimen)
NOTE: During the assessment phase, the nurse collects a
comprehensive information base about the patient from the
physical examination, nursing history, medication history, and
professional observation.
FORMATS FOR DATA COLLECTION
A. Head- to- toe assessment
B. Body systems assessments
C. Gordons Functional Health Patterns Model P.39 Clayton
D. 13 Areas of Assessment
a. Past history
Chronic conditions
Drug use Allergies
Level of education
Level of understanding of disease and therapy
Social supports
Financial supports Pattern of health care
b. Physical examination
Weight
Age
Physical parameters related to the disease state or
known drug effects
 Drug Therapy
• It is a complex and important part of health care, and the
principles of drug therapy must be incorporated into
every patient assessment plan.
• The particular information that is needed varies with
each drug, but the concepts involved are similar.
• Two major aspects associated with assessment are:
a. Patient's History (past illnesses and the current
problem)
b. Physical Examination
• a. Patient's History
The patient's history is an important element of
assessment related to drug therapy because his or
her past experiences and illnesses can influence a
drug's effect. Knowledge of this important information
before beginning drug therapy will help to
promote safe and effective use of the drug and
prevent adverse effects, clinically important drug-
drug, drug-food, or drug-alternative therapy inter-
actions, and medication errors.
• Relevant aspects of the patient's history specifically
related to drug therapy are the ff:
a.a History
a.b. Chronic Condition
a.c Drug Use
a.d Allergy
a.e Level of Education and Understanding
a.f Social Supports
a.g Financial Supports
a.h Pattern of Health Care
b. Physical Examination
It is important to assess the patient's physical
status before beginning drug therapy to determine
if any conditions exist that would be
contraindications or cautions for using the drug
and to develop a baseline for evaluating the
effectiveness of the drug and the occurrence of any
adverse effects.
• Relevant aspects of the patient's physical examination
specifically related to drug therapy are the ff:
b.a Weight
b.b Age
b.c Physical Parameters Related to Disease or Drug
Effects
B2. Nursing Diagnosis
• A nursing diagnosis is simply a statement of the
patient's status from a nursing perspective. The
nurse analyzes the information gathered during
assessment to arrive at some conclusions that lead
to a particular goal and set of interventions.
• A nursing diagnosis shows actual or potential
alterations in patient function based on assessment
of the clinical situation. Because drug therapy is
only a small part of the overall patient situation,
nursing diagnoses that are related to drug therapy
must be incorporated into a total picture of the
patient.
• The diagnoses from the North American Nursing
Diagnosis Association (NANDA-I) list are the
accepted nursing diagnoses and are only a part of
the overall nursing diagnoses related to the
patient's situation.
 NANDA-I Approved Nursing
Diagnoses (2011)
• Activity Intolerance
• Activity Intolerance, Risk for
• Ineffective Activity Planning
• Airway Clearance, Ineffective
• Allergy Response, Latex
• Allergy Response, Risk for Latex
• Anxiety
• Anxiety, Death
• Aspiration, Risk for
Page 47 Focus on Nursing Pharmacology.
 B3. Planning
• Planning involves taking and
prioritizing the information
gathered and synthesized in the
nursing diagnoses to plan the
patient care. This process includes
setting goals and desired patient
outcomes to assure safe and
effective drug therapy. These
outcomes usually involve ensuring
effective response to drug therapy,
minimizing adverse effects, and
understanding the drug regimen.
 PLANNING
- May be individualized.
- Their is measurable goals.
- There is anticipated therapeutic outcomes that can be identified.
a. Prioritize the problems identified from the assessment data, with
the most severe or life-threatening first.
a. 1. Other problems are arranged in descending order of
importance.
a. 2. Maslow’s hierarchy is frequently used as a basis for
prioritizing.
b. Develop short and long term patient goals/ outcomes in measurable
statements appropriate to the clinical setting and length of stay .
c. Identify the monitoring parameters to be used to detect
possible complications of the disease process or treatments
being used.
d. Plan nursing approaches to correlate with each identified
patient goal/outcome.
e. Integrate outcomes/ classification systems into critical
pathways and/ or standardized care plans utilized in clinical
settings.
 B4. Implementation

Implementation
involves nursing
interventions
aimed at achieving
the goals of
outcomes
determined in the
planning phase.
 Implementation/ intervention
- Consider the individual’s physical, psychological and cultural needs. (Holistic
approach)
a. Perform the nursing intervention planned to achieve the established goals/
outcomes.
b. Monitor the patient’s response to treatments, and monitor for complications
related to existing pathophysiology.
c. Provide for patient safety.
d. Perform ongoing assessments on a continuum.
e. Document care given and additional findings on the patient chart.
f. Comfort measures
Placebo effect
Managing side effects
Lifestyle adjustments
G. Patient/family education
Three types of nursing interventions are frequently
involved in drug therapy:
a. Drug Administration
a.a 12 Rights of Drug Administration (ANSAP (2016), Nursing
Standard on Intravenous Practice, 11th Edition)
- Right Medication - Right Reason
- Right Client - Right Documentation
- Right Time - Right Assessment and Evaluation
- Right Route - Right Client Education
- Right Dose - Right to Refuse Medication
- Right Response - Right to Receive up to date
Medication
Proper drug administration
Drug
Storage
Route
Dose
Preparation
Timing
Recording
• b. Provision of Comfort
Measures
b.a Placebo Effect
The anticipation that a
drug will be helpful (placebo
effect) has proven to have
tremendous impact on the actual
success of drug therapy.
Therefore, the nurse's attitude
and support can be a
critical part of drug therapy.
b.b Managing Adverse Effects
Interventions can be
directed at promoting patient safety
and decreasing the impact of
the anticipated adverse effects of a
drug.
– Eg: Environmental control
(e.g., temperature, light),
safety measures (e.g,
avoiding driving, avoiding
the sun, using side rails), and
physical comfort measures
(e.g., skin care, laxatives,
frequent meals).
b.c Lifestyle
Adjustments
Some
medications and their
effects require that a
patient make changes
in his or her lifestyle.
c. Patient and Family Education
 B5. Evaluation

• Evaluation is part of the

continuing process of patient
care that leads to changes in
assessment, diagnosis,
planning, and intervention.
The patient is continually
evaluated for therapeutic
response, the occurrence of
adverse drug effects, and the
occurrence of drug-drug,
drug-food, drug-alternative
therapy, or drug-laboratory
test interactions.
 EVALUATION

a. An ongoing process that occurs at every phase of the nursing

process. Establish target data to review and analyze at
intervals prescribed by guidelines in the practice setting.
b. Review and analyze the data regarding the patient and modify
the care plan so that goals/ outcomes of care ( used to return
the patient to the highest level of functioning) are attained.
c. Unrealistic goals/ outcomes may require revision or
discontinuation.
d. Follow a systematic approach to recording progress,
depending on the setting and charting methodology. Ei. SOPIE,
DAR.
 RECALL
• Assessment: information gathering regarding the current
status of a particular patient, including evaluation of past
history and physical examination; provides a baseline of
information and clues to effectiveness of therapy
• Evaluation: part of the nursing process; determining the
effects of the interventions that were instituted for the patient
and leading to further assessment and intervention
• Implementation: actions undertaken to meet a patient’s
needs, such as administration of drugs, comfort measures, or
patient teaching
 RECALL
• Nursing diagnosis: statement of an actual or potential problem,
based on the assessment of a particular clinical situation, which
directs needed nursing interventions
• Nursing process: the problem-solving process used to provide
efficient nursing care; it involves gathering information,
formulating a nursing diagnosis statement, carrying out
interventions, and evaluating the process
 C. Medication Errors
• There is no consensus about the
definition of a medication error. A
systematic literature review found
26 different terminologies
employed for a medication error.
• The United States National Coordinating
Council for Medication Error Reporting
and Prevention defines a medication
error as:
– “any preventable event that may cause or lead to
inappropriate medication use or patient harm while
the medication is in the control of the health care
professional, patient, or consumer. Such events may
be related to professional practice, health care
products, procedures, and systems, including
prescribing, order communication, product
labelling, packaging, and nomenclature,
compounding, dispensing, distribution,
administration, education, monitoring, and use”
• This definition is broad and suggests that
errors are preventable at different levels.
Medication error has also been defined as
a reduction in the probability of
treatment being timely and effective, or
an increase in the risk of harm relating to
medicines and prescribing compared
with generally accepted practice.
• There are several different approaches to classifying
medication errors.
• One approach is to base the classification on the stage
in the sequence of medication use process, such as
prescribing, transcribing, dispensing, administration or
monitoring.
• Another approach is to consider the types of errors
occurring, such as wrong medication, dose, frequency,
administration route or patient.
• A further approach classifies errors according to
whether they occur from mistakes made when
planning actions (knowledge-based or rule-based
mistakes) or errors in the execution of appropriately
planned actions (action-based errors, known as “slips”,
or memory-based errors, known as “lapses”).
• Errors may also be classified according to
their level of severity.
• These approaches are not mutually
exclusive and there is no strong evidence
to support particular methods of defining
or classifying errors specifically in
primary care.
• The approach taken will depend on the
setting and the purpose of the
classification.
• With the increase in the older adult patient population,
the increase in the number of available drugs and OTC
and alternative therapy preparations, and the reduced
length of hospital stays for patients, the risk for
medication errors is ever increasing.
• The drug regimen process, which includes prescribing,
dispensing, and administering a drug to a patient, has a
series of checks along the way to help to catch errors
before they occur.
• Often the nurse is the final check in the process because
the nurse is the one who administers the drug and is
the one responsible for patient education before the
client is discharge at home.
 Factors that may influence
medication errors
• Factors associated with health care professionals
– Lack of therapeutic training
– Inadequate drug knowledge and experience
– Inadequate knowledge of the patient
– Inadequate perception of risk
– Overworked or fatigued health care professionals
– Physical and emotional health issues
– Poor communication between health care
professional and with patients
• Factors associated with patients
– Patient characteristics (e.g., personality,
literacy and language barriers)
– Complexity of clinical case, including
multiple health conditions, polypharmacy
and high-risk medications
• Factors associated with the work
environment
– Workload and time pressures
– Distractions and interruptions (by both
primary care staff and patients)
– Lack of standardized protocols and
procedures
– Insufficient resources n Issues with the
physical work environment (e.g., lighting,
temperature and ventilation)
• Factors associated with tasks
– Repetitive systems for ordering, processing
and authorization
– Patient monitoring (dependent on practice,
patient, other health care settings, prescriber)
• Factors associated with medicines
– Naming of medicines
– Labelling and packaging
• Factors associated with computerized
information systems
– Difficult processes for generating first
prescriptions (e.g. drug pick lists, default
dose regimens and missed alerts)
– Difficult processes for generating correct
repeat prescriptions
– Lack of accuracy of patient records
– Inadequate design that allows for human
error
• Primary-secondary care interface
– Limited quality of communication with
secondary care
– Little justification of secondary care
recommendations
• C1. Nurses Role
The monumental task
for ensuring medication
safety with all of the potential
problems that could confront
the patient can be best
manage by consistently using
the 12 rights of medication
administration.
C2. Clients Role
The ff: teaching points help to reduce the medication
errors in the home setting:
• Keep a written list of all medications taken including
prescription, OTC and herbal medication.
• Know what each of your drugs is being used to treat.
• Read the labels and follow the directions
• Store drugs in dry place, away from children and pets
• Speak Up.
When teaching parents about their children’s drug
regimen in a safe and effective way.
• Keep a list of all medications you are giving your child,
including prescription, OTC and herbal medication.
• Never use adult medication to treat a child
• Read all labels before giving your child a drug
• Measure liquid medications using appropriate
measuring devices.
• Call your health care provider immediately if your child
seems to get worse or seems to be having trouble with
a drug.
• When in doubt, do not hesitate to ask questions. You
are your best child’s advocate.
C3. Reporting of Medication Errors
• Medication errors must be reported on a
national level as well as on an
institutional level.
• The reports might prompt the issuing of
health care provider warnings, which
point out medication errors and suggest
ways to avoid errors in the future.
• For example, in 2007, the
name of the drug Omacor
(omega-3 fatty acid) was
changed to Lovaza after many
reports of confusion between
Omacor and Amicar
(aminocaproic acid). Other
reports have led to public
warnings about look-alike or
sound-alike drug names and
common dosing errors and
transcribing issues.
ADIOS!