Nursing Process in Patient-Centered Pharmacotherapy

The Nursing Process in Patient-Centered Pharmacotherapy

• The nursing process consists of five phases: Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation.

Assessment

• Involves systematic validation and documentation of patient information, forming the basis for diagnosis.
• Subjective Data: Information described by the patient, including current history, symptoms, medications, past history, and environment.
• Objective Data: Measurable signs detected by another person, such as physical assessments, lab tests, and diagnostic tests.

Factors Affecting Medication Adherence

• Common factors leading to nonadherence include forgetfulness, family issues, knowledge deficits, language barriers, side effects, cost, low self-esteem, anxiety, depression, and trust issues in healthcare systems.

Nursing Diagnosis

• Derived from an analysis of assessment data, nursing diagnoses address actual problems or risk factors and guide the creation of personalized care plans.
• Examples include pain related to fear of addiction, acute confusion from medication reactions, and knowledge deficiencies regarding anticoagulants.

Planning

• Characterized by goal setting with realistic, measurable outcomes and defined timelines for re-evaluation.
• Goals must be patient-centered, acceptable to both patient and nurse, and shared with the healthcare team and family.

Implementation and Nursing Interventions

• Focuses on education, medication administration, patient care, and other interventions.
• Effective patient teaching depends on understanding the patient's readiness to learn, attention span, and motivation.

Inclusion of Family Members

• Family members can provide psychological support, assist in therapy administration, observe effectiveness and side effects, and help implement care changes.

Patient Education Topics

• Cover adherence, self-administration skills, dietary guidelines, side effects management, and cultural considerations.

Evaluation

• Assesses the degree of goal attainment.
• If goals are unmet, collaboration with the patient and family helps identify reasons and adjust plans.

Safety and Quality in Pharmacotherapy

• Follow the "Five-Plus-Five Rights of Medication Administration": right patient, drug, dose, route, time, assessment, documentation, patient education, evaluation, and the right to refuse.

Medication Administration Guidelines

• Identify patients with two forms of ID before medication administration.
• Ensure medications are given via the correct route for effective absorption and check for contraindications.
• Assess swallowing capabilities and nurse interventions such as observing drug ingestion.

Documentation and Reporting

• Proper documentation includes drug name, dose, route, time, the nurse's signature, and patient responses.
• Report medication errors immediately and complete incident reports.

Medication Error Prevention

• Utilize technology such as barcoding, maintain lists of acceptable abbreviations, and ensure proper drug reconciliation during transitions.

Medication Reconciliation

• Involves comparing a patient's current medications against new orders during transitions such as admission, transfer, or discharge.

Forms and Routes of Drug Administration

• Common routes include sublingual, oral, transdermal, topical, and parenteral (IV, IM, SC).
• Emphasize proper administration techniques for each route to prevent errors and maximize efficacy.

Special Considerations

• Use child-resistant packaging for pediatric medications.
• Inhalation methods require precise techniques, including the use of metered-dose inhalers and nebulizers for effective delivery.
• Ensure all recording and charting are prompt, particularly for any PRN medications.

Storage and Disposal

• Controlled substances must be securely stored and disposed of according to established protocols.
• Report any drug waste according to agency policy and ensure safe disposal methods are followed.

Explore the critical phases of the nursing process in patient-centered pharmacotherapy. This quiz covers assessment, nursing diagnosis, planning, implementation, and evaluation, emphasizing the importance of systematic validation and documentation. Test your understanding of these essential concepts in nursing practice.