The Nursing Process - Pharmacology

The nursing process is a systematic way a nurse decides how to treat the patient’s responses to health and illness. There are five steps in the nursing process:

  1. Assessment
  2. Diagnosis
  3. Planning
  4. Intervention/Implementation
  5. Evaluation

Assessment is data collection. During the assessment step, the nurse is gathering subjective and objective data from the patient that will later be used to arrive at a nursing diagnosis. Subjective data is information that is reported by the patient such as, “I’m feeling warm.” Objective data is information that can be measured or observed, such as the patient’s temperature or the color of the patient’s skin.

Diagnosis is the patient’s problem, which is determined by analyzing data collected during the patient’s assessment. The data could lead the nurse to determine that the patient has more than one problem. This diagnosis is referred to as a nursing diagnosis. A nursing diagnosis is different from a medical diagnosis.

For example, a nurse might diagnose an alteration in mobility in a patient who has had a stroke. Aphysician or advanced nurse practitioner determines the medical diagnosis, which is cerebral vascular accident (CVA). The nurse might also determine this patient has a potential for alteration in nutrition because he or she is having difficulty swallowing because of the stroke.

The plan is how the nurse proposes to treat the nursing diagnosis. The plan takes the form of a care plan that itemizes the patient’s nursing diagnosis. Each nursing diagnosis will have an expected outcome or goal. The care plan contains at least one nursing intervention for each nursing diagnosis, the expected outcome for each intervention, and how the nurse will evaluate the outcome. For example, the final outcome goal for an alteration in mobility might be to have the patient get out of bed and ambulate without assistance. However, the interventions will begin with getting the patient out of bed and to the chair or assisting the patient to walk short distances each day.

The intervention is executing the plan. For example, the nurse will assist the patient to the chair the first time and might delegate the task to a nursing assistant thereafter if the patient does not have any problems.

The evaluation step of the nursing process determines if the intervention worked. For example, the nurse evaluates the patient’s response to getting out of bed and also determines if the patient continues to get out of bed on a daily basis. If the patient continues to have no problems getting out of bed, the nurse may change the interventions to include walking short distances in addition to getting out of bed and increase those distances each day. When the patient is able to get out of bed and walk without assistance, the final goal will have been achieved. The nursing process is circular. If the nurse determines during the evaluation step that the intervention didn’t work or the expected outcome has been achieved, the nurse begins the nursing process again, starting with the assessment step and then revises the care plan as the patient’s problem changes. The nursing process is repeated until the patient’s problem(s) is resolved.

ASSESSMENT RELATED TO DRUGS

During the assessment phase, the nurse systematically collects, verifies, and analyzes

patient-related data. A portion of the assessment process directly relates to administering medication to the patient.

Before medication is given to a patient, the nurse must make the follow assessments.

Is the drug order valid?

A drug order must be written by a physician, dentist, physician assistant, or advanced practice nurse and contain:

  • The date and time the order is written
  • The name of the drug
  • The dosage
  • The route of administration
  • The frequency of administration
  • The duration (how long the patient is to receive the drug)
  • The signature of the prescriber

Identify the brand and generic name for the drug

Drugs are known under several names. These are

  • The chemical name used by pharmacists and researchers
  • The generic name, which is the official (proprietary) non-proprietary name that is universally accepted
  • The brand name, which is the name chosen by the drug manufacturer
  • The official name that appears in the USP-NF

When is the drug used?

The nurse is required to know why the drug is given to the patient and what symptoms a patient exhibits to indicate that the drug should be administered. The nurse cannot rely solely on the prescriber because the patient’s condition might have changed since the patient was assessed. Furthermore, there is always a potential that the order is in error. There are a variety of reasons an order can be in error. These include, but are not limited to, writing an order or a prescription for the wrong patient, for a drug to which the patient is allergic, for a drug that will interact badly with another drug the patient is taking, a dose that is too small or too large for the patient based on weight, or simply the wrong drug. Medication errors can be reduced or eliminated if everyone involved in the process uses critical thinking skills and checks and double checks the orders, the patient, and the medication.

How does the drug work?

It is critical that the nurse understands how the drug is absorbed, distributed, metabolized, and eliminated before administering the drug to the patient. One of these mechanisms might be malfunctioning. For example, the patient might have lower than expected urinary output and is unable to excrete the drug in normal volume resulting in a potential toxic buildup in the body.

The nurse must also know the drug’s onset of action, peak action, and duration of action. As you’ll recall from the previous chapter, onset is the time period when the drug reaches the minimally effective concentration in the plasma. The peak action is when the drug reaches the maximum concentration in the plasma. The duration is the length of time the therapeutic action will last.

What interacts with the drug?

The effectiveness of a drug can be influenced by interactions with food, herbal remedies, and other drugs that alter or modify the drug’s action. Such interactions might increase the drug’s effectiveness, decrease it, or neutralize it. The nurse must be aware of known interactions in order to avoid them.

What are the side effects and toxicity of the drug?

A side effect is a physiological response in the patient’s body that is not related to the drug’s primary action. Some side effects are beneficial while side effectssuch as nausea and vomitingare undesirable. By knowing a drug’s possible side effects, the nurse can prepare to manage them before the patient is given the drug.

The nurse must also know the toxicity of a drug. A drug’s toxicity is the drug concentration in plasma and accumulation in tissues that exceeds the drug’s therapeutic range.

What signs and symptoms must be monitored?

The nurse must note the signs and symptoms that indicate the patient is having an adverse reaction to a drug or that the drug has reached toxic levels. These indications may not be present for minutes, hours, and even days after the drug is administered.

What must a patient know about the drug?

Many drugs are self-administered by patients after they leave the healthcare facility. Therefore it is important that the nurse identify information about the drug that the patient needs to know to properly administer the drug.

Is the drug available? Has the drug expired? How much does the drug cost?

The drug that is ordered may not be available in the healthcare facility. The nurse must make sure the drug is available and make sure that the drug on hand hasn’t expired if it is available. For example, some healthcare facilities might have a very low requirement for a particular drug and the stock of the drug might be old and have passed the expiration date.

The cost of the drug is important to know for a number of reasons. Some drugs are not covered by the patient’s health insurance because they are expensive. The insurance company may cover the cost of a similar medication that costs less. In addition, many patients do not have insurance to cover medications and they cannot afford to have an expensive prescription filled. Nurses should ask patient’s about their insurance coverage and if they can afford to buy the medication if they don’t have coverage. Many patients might stop taking an important medication because they don’t have enough money.

Patient information

Before administering a drug, the nurse must review information about the patient to assure that the patient will not have an adverse reaction to the drug.

The nurse must determine:

  • Does the patient have any allergies to the drug or to food that might be given along with the drug?
  • Has the patient’s condition changed since the drug was ordered?
  • What is the patient’s age?
  • What is the appropriate dose of the drug based upon the patient’s weight?
  • What is the patient’s gender?
  • Is the patient pregnant?
  • What is the patient’s primary language?
  • Are there any religious or cultural influences that would cause the patient to resist taking the medication?
  • Does the patient know and understand the purpose of the medication?
  • Does the patient’s history include taking vitamins, birth control pills, and herbal remedies?
  • Does the patient use illegal drugs or alcohol?
  • Does the patient have a tolerance for the drug that is being administered?
  • Are there any genetic factors that might cause an adverse reaction by taking the medication?
  • Are there any emotional factors that can affect the patient’s ability to take the drug?
  • Are there any contraindications for the medication that are indicated by taking vital signs and reviewing current laboratory and diagnostic tests?
  • Is the patient’s mental status sufficient so that the patient understands why medication is being administered? Is there someone available to monitor the patient?
  • Can the patient afford the medication?
  • Will family members or friends be with the patient to monitor for side effects and toxicity?
  • Is the patient scheduled for tests, procedures, or other activities at the same time he or she is scheduled to receive medication?
  • Is the patient scheduled to receive medication during visiting hours?
  • Is the patient required to have a procedure performed, such as insertion of an IV or feeding tube before medication is administered?

Getting this information may sound overwhelming to the new nurse. However, a lot of this information has already been obtained when the patient is admitted or arrived at the office or clinic for care.


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