The Nursing Process In Drug Therapy & Patient Safety PDF

The Nursing Process in Drug Therapy and Patient Safety Prepared By Jonathan Q. Ibalio, MD College  INTRODUCTION The delivery of medical care today is in a constant state of change, at times reaching crisis levels. The population is aging, re...

The Nursing Process in Drug Therapy and Patient Safety Prepared By Jonathan Q. Ibalio, MD College  INTRODUCTION The delivery of medical care today is in a constant state of change, at times reaching crisis levels. The population is aging, resulting in an increased incidence and prevalence of chronic disease and more complex care issues. The population also is more transient, with individuals and families more mobile, often resulting in unstable support systems and fewer at-home care providers and helpers. The Nursing  INTRODUCTION At the same time, health care is undergoing a technological boom, including greater use of more sophisticated diagnostic methods and treatments, new specialized drugs, including experimental drugs, and so on. Moreover, patients are being discharged earlier from acute care facilities or are not being admitted at all for procedures that used to be treated in-hospital with follow-up support and monitoring. The Nursing  INTRODUCTION Patients also are becoming more responsible for their care and for adhering to complicated medical regimens at home. The wide use of the Internet and an emphasis in the media on the need to question all aspects of health care has led to more knowledgeable and challenging patients. Patients may no longer accept a drug regimen or therapy without question and often feel confident in adjusting it on their own because of information that they have found on the Internet—information that might not be very accurate or even relevant to their particular situation. The Nursing  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  NURSING: ART AND SCIENCE The nurse deals with the whole person, including physical, emotional, intellectual, social, and spiritual aspects. Nurses must consider how a person responds to disease and its treatment, including the changes in lifestyle that may be required. Therefore, a nurse is a key health care provider who is in a position to assess the whole patient, to administer therapy as well as medications, to teach the patient how best to cope with the therapy so as to ensure the most favorable outcome, and to evaluate the effectiveness of the therapy. The Nursing  NURSING: ART AND SCIENCE Nurses accomplish these tasks by integrating knowledge of the basic sciences (anatomy, physiology, nutrition, chemistry, pharmacology), the social sciences (sociology, psychology), education, and many other disciplines and applying the nursing process. The Nursing  THE NURSING PROCESS Nurses use the nursing process—a decision-making, problem- solving process—to provide efficient and effective care. A Although not all nursing theorists completely agree on this process that defines the practice of nursing, most do include certain key elements: assessment, nursing diagnosis, implementation, and evaluation. Application of the nursing process with drug therapy ensures that the patient receives the best, safest, most efficient, scientifically based,holistic care. The Nursing  THE NURSING PROCESS Assessment Assessment (gathering information) 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, 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. The Nursing  THE NURSING PROCESS Assessment Each nurse develops a unique approach to the organization of the assessment, an approach that is functional and useful in the clinical setting and that makes sense to that nurse and in the particular clinical situation. Regardless of the approach, the process of assessment never ends because the patient is in a dynamic state, continuously adjusting to physical, emotional, and environmental influences. Drug therapy is a complex and important part of health care, and the principles of drug therapy must be incorporated into every patient assessment plan. The Nursing  THE NURSING PROCESS Assessment 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 interactions, and medication errors. The Nursing  THE NURSING PROCESS Assessment History Chronic Conditions - Chronic conditions can affect the pharmacokinetics and pharmacodynamics of a drug. For example, certain conditions (e.g., renal disease, heart disease, diabetes, chronic lung disease) may be contraindications to the use of a drug. In addition, these conditions may require cautious use or dose adjustment when administering a certain drug. The Nursing  THE NURSING PROCESS Assessment History Chronic Conditions For example, a patient with renal disease may require a decreased dose of a drug due to the way the drug is eliminated. If renal disease is mentioned in the patient history, the nurse should consider this factor to evaluate the dose of the drug that is prescribed. The Nursing  THE NURSING PROCESS Assessment History Drug Use - Prescription drugs, over-the-counter (OTC) drugs, street drugs, alcohol, nicotine, alternative therapies, and caffeine may have an impact on a drug’s effect. Patients often neglect to mention OTC drugs or alternative therapies because they do not consider them to be actual drugs or they may be unwilling to admit their use to the health care provider. The Nursing  THE NURSING PROCESS Assessment History DrugUse Ask patients specifically about OTC drug or alternative therapy use. Patients also might forget to mention prescription drugs that they routinely take all the time, for instance, oral contraceptives. Always ask specifically about all types of medications that the patient might use. The Nursing  THE NURSING PROCESS Assessment History Allergies - A patient’s history of allergies can affect drug therapy. Past exposure to a drug or other allergens can provoke a future reaction or necessitate the need for cautious use of the drug, food, or animal product. Obtain specific information about the patient’s allergic reaction to determine whether the patient has experienced a true drug allergy or was experiencing an actual effect or adverse effect of the drug. The Nursing  THE NURSING PROCESS Assessment History Level of Education and Understanding - Information about the patient’s education level provides a baseline from which the nurse can determine the appropriate types of teaching information to use with the patient. A patient with a fifth grade education may require materials at a different level than a patient with a graduate degree. The Nursing  THE NURSING PROCESS Assessment History Level of Education and Understanding Gathering information about the patient’s level of understanding about his or her condition, illness, or drug therapy helps the nurse to determine where the patient is in terms of his or her status and the level of explanation that will be required. It also provides additional baseline information for developing a patient education program. The Nursing  THE NURSING PROCESS Assessment History Level of Education and Understanding It is important not to assume anything about the patient’s ability to understand based on his or her reported education level. Stress,disease, and environmental factors can all affect a patient’s learning readiness and ability. Direct assessment of actual learning abilities is critical for good patient education. The Nursing  THE NURSING PROCESS Assessment History Social Supports - Patients are being discharged from health care facilities earlier than ever before, often with continuing care needs. In addition, earlier discharges leave minimal time for teaching. Often patients need help at home with care and drug therapy. A key aspect of discharge planning involves determining what support, if any, is available to the patient at home. In many situations, it also involves referral to appropriate community resources. The Nursing  THE NURSING PROCESS Assessment History Financial Supports - The high cost of health care in general, and of medications in particular, must be considered when initiating drug therapy and promoting patient compliance. Financial constraints may cause a patient not to follow through with a prescribed drug regimen. For example, the drug may be too expensive or the patient may lack the means to get to a pharmacy to obtain the drug. In some situations, a less expensive drug might be appropriate in place of a very expensive drug.. The Nursing  THE NURSING PROCESS Assessment History Pattern of Health Care - Knowing how a patient seeks health care provides the nurse with valuable information to include when preparing the patient’s teaching plan. Does this patient routinely seek follow-up care, or does he or she wait for emergency situations? Does the patient tend to self-treat many complaints, or is every problem brought to a healthcare provider? The Nursing  THE NURSING PROCESS Assessment History Pattern of Health Care Information about patterns of health care also provides insight into conditions that the patient may have but has not reported or medication use that has not been stated. The Nursing  THE NURSING PROCESS Assessment Physical Examination Weight - A patient’s weight helps to determine whether the recommended drug dose is appropriate. Because the recommended dose typically is based on a 150-pound adult man, patients who are much lighter or much heavier often need a dose adjustment. Age - Patients at the extremes of the age spectrum—children and older adults—often require dose adjustments based on the functional level of the liver and kidneys and the responsiveness of other organs. The Nursing  THE NURSING PROCESS Assessment Physical Examination Age The child’s age and developmental level will also alert the nurse to possible problems with drug delivery, such as the ability to swallow pills or follow directions related to other delivery methods. The child’s developmental age will also influence pharmacokinetics and pharmacodynamics; the immature liver may not metabolize drugs in the same way as in the adult, or the kidneys may not be as efficient as those of an adult. The Nursing  THE NURSING PROCESS Assessment Physical Examination Age As patients age, the body undergoes many normal changes that can affect drug therapy, such as a decreased blood volume, decreased gastrointestinal absorption, reduced blood flow to muscles or skin, and changes in receptor-site responsiveness. Older adults may often have a variety of chronic medical conditions and could be receiving a number of medications that need to be evaluated for possible interactions. The Nursing  THE NURSING PROCESS Assessment Physical Examination Age Older adults with various central nervous system disorders like Alzheimer’s disease or Parkinson’s disease, may develop difficulty swallowing and might require liquid forms of medication.. Physical Parameters Related to Disease or Drug Effects - The specific parameters that need to be assessed depend on the disease process being treated and on the expected therapeutic and adverse effects of the drug therapy. The Nursing  THE NURSING PROCESS Assessment Physical Examination Physical Parameters Related to Disease or DrugEffects Assessing these factors before drug therapy begins provides a baseline level to which future assessments can be compared to determine the effects of drug therapy. For example, if a patient is being treated for chronic pulmonary disease, his or her respiratory status and reserve need to be assessed, especially if a drug is being given that is known to affect the respiratory tract. The Nursing  THE NURSING PROCESS Assessment Physical Examination Physical Parameters Related to Disease or DrugEffects In contrast, a thorough respiratory evaluation would not be warranted in a patient with no known pulmonary disease who is taking a drug with little or no known effects on the respiratory system. Because the nurse has the greatest direct and continued contact with the patient, the nurse is in the best position to detect minute changes that ultimately determine the course of drug therapy— The Nursing  THE NURSING PROCESS Assessment Physical Examination Physical Parameters Related to Disease or DrugEffects ---therapeutic success or discontinuation because of adverse or unacceptable responses. The Nursing  THE NURSING PROCESS Nursing Diagnosis A nursing diagnosis is simply astatement 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 the assessment of the clinical situation. The Nursing  THE NURSING PROCESS Nursing Diagnosis 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 nursing diagnoses listed are those that reflect potential alteration of function based only on the particular drug’s actions (i.e., therapeutic and adverse effects). No consideration is given to environmental or disease related problems. The Nursing  THE NURSING PROCESS Nursing Diagnosis These diagnoses, culled from the North American Nursing Diagnosis Association (NANDA-I) list of accepted nursing diagnoses, are only a part of the overall nursing diagnoses related to the patient’s situation. The Nursing  THE NURSING PROCESS Implementation Implementation involves taking the information gathered and synthesized into 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. Three types of nursing interventions are frequently involved in drug therapy: drug administration, provision of comfort measures, and patient/family education. The Nursing  THE NURSING PROCESS Implementation Proper DrugAdministration The nurse must consider seven points, or “rights,” to ensure safe and effective drug administration. These are: 1. correct drug and patient, 2. correct storage of drug, 3. correct and most effective route, 4. correct dose, 5. correct preparation, 6. correct timing,and 7. correct recording of administration. The Nursing  THE NURSING PROCESS Implementation Proper DrugAdministration Remembering to review each point before administering a drug will help to prevent medication errors and improve patient outcomes. The Nursing  THE NURSING PROCESS Implementation Comfort Measures Nurses are in a unique position to help the patient cope with the effects of drug therapy. A patient is more likely to be compliant with a drug regimen if the effects of the regimen are not too uncomfortable or overwhelming. Placebo Effect - The anticipation that a drug will be helpful (placebo effect) has proved to have tremendous impact on the actual success of drug therapy. The Nursing  THE NURSING PROCESS Implementation Comfort Measures Placebo Effect Therefore, the nurse’s attitude and support can be a critical part of drug therapy. For example, a back rub, a kind word, and a positive approach may be as beneficial as the drug itself. Managing Adverse Effects - Interventions can be directed at promoting patient safety and decreasing the impact of the anticipated adverse effects of a drug. The Nursing  THE NURSING PROCESS Implementation Comfort Measures ManagingAdverse Effects Such interventions include 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). Lifestyle Adjustment - Some medications and their effects require that a patient make changes in his or her lifestyle. The Nursing  THE NURSING PROCESS Implementation Comfort Measures Lifestyle Adjustment - For example, patients taking diuretics may have to rearrange their day so as to be near toilet facilities when the drug action peaks. Patients taking bisphosphonates will need to plan their morning so they can take the drug on an empty stomach, stay upright for at least one-half hour, and plan their first food of the day at least one-half hour after taking the drug. The Nursing  THE NURSING PROCESS Implementation Comfort Measures Lifestyle Adjustment - Many drugs come with similar guidelines for assuring effectiveness and decreasing adverse effects. Patients taking monoamine oxidase inhibitors must adjust their diet to prevent serious adverse effects due to potential drug– food interactions. In some cases, the change in lifestyle that is needed can have a tremendous impact on the patient and can affect his or her ability to cope and comply with any medical regimen. The Nursing  THE NURSING PROCESS Implementation Patient and Family Education With patients becoming increasingly responsible for their own care, it is essential that they have all of the information necessary to ensure safe and effective drug therapy at home. In fact, many states now require that patients be given written information. Box 4.3 includes key elements for any drug education program. The Nursing  THE NURSING PROCESS Evaluation Evaluation is part of the continuing process of patient care that leads to changes in assessment, diagnosis, 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. Some drug therapy requires evaluation of specific therapeutic drug levels. In addition, the efficacy of the nursing interventions and the education program also are evaluated. The Nursing  THE NURSING PROCESS Evaluation In some situations, the nurse evaluates the patient simply by reapplying the beginning steps of the nursing process and then analyzing for changes, either positive or negative. The process of evaluation may lead to changes in the nursing interventions being used to provide better and safer patient care. The Nursing  PREVENTION OF MEDICATION ERRORS 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. In 2000, the Institute of Medicine published a large-scale study of medication errors in the United States, entitled To Err Is Human: Building a Safer Health System. It reported that 44,000 reported deaths in hospitals each year occurred from medication errors, and that the number could probably be closer to 98,000. The Nursing  PREVENTION OF MEDICATION ERRORS The study brought to light the many places in the system where a medication error could occur and suggested methods for improving the problem. 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. These include the physician or nurse practitioner who prescribes a drug, the pharmacist who dispenses the drug, and the nurse who administers the drug. The Nursing  PREVENTION OF MEDICATION ERRORS Each serves as a check within the system to catch errors—the wrong drug, the wrong patient, the wrong dose, the wrong route, or the wrong time. 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 patient is discharged to home. The Nursing  PREVENTION OF MEDICATION ERRORS Nurse’s Role The monumental task of ensuring medication safety with all of the potential problems that could confront the patient can best be managed by consistently using the “rights” of medication administration. These rights are as follows: 1. Right patient. 5. Right dose. 2. Right drug. 6. Right preparation. 3. Right storage. 7. Right time. 4. Right route. The Nursing  PREVENTION OF MEDICATION ERRORS The Patient’s Role With so many patients managing their drug regimens at home, one other very important check in the system also exists: the patient. Only the patient really knows what is being taken and when, and only the patient can report the actual as opposed to the prescribed drug regimen being followed. Patient and family education plays a vital role in the prevention of medication errors. Encourage patients to be their own advocates and to speak up and ask questions. the home setting: The Nursing  PREVENTION OF MEDICATION ERRORS The Patient’s Role Doing so helps to prevent medication errors. The following teaching points help to reduce the risk of medication errors in the home setting: 1. Keep a written list of all medications you are taking, including prescription, OTC, and herbal medications. 2. Know what each of your drugs is being used to treat. 3. Read the labels, and follow the directions. 4. Store drugs in a dry place, away from children and pets. 5. Speak up. The Nursing  PREVENTION OF MEDICATION ERRORS The Patient’s Role Children present unique challenges related to medication errors. Children often cannot speak for themselves and rely on a caregiver or caregivers to manage their drug regimen. Because their bodies are still developing and respond differently than those of adults to many drugs, the risk of serious adverse reactions is greater with children. The margin of safety with many drugs is very small when dealing with a child. The Nursing  PREVENTION OF MEDICATION ERRORS The Patient’s Role When teaching parents about their children’s drug regimens, be sure to include the following instructions: 1. Keep a list of all medications you are giving your child, including prescription, OTC, and herbal medications. 2. Never use adult medications to treat a child. 3. Read all labels before giving your child a drug. 4. Measure liquid medications using appropriate measuring devices. The Nursing Thank you…