3 The Nursing Process in Patient-Centered Pharmacotherapy.pdf

The Nursing Process in Patient-Centered Pharmacotherapy Phases: Assessment Nursing Diagnosis Planning Implementation Evaluation The Nursing Process in Patient-Centered Pharmacotherapy Assessment - systemic validation and documentation of information - made throughout the nsg...

The Nursing Process in Patient-Centered Pharmacotherapy Phases: Assessment Nursing Diagnosis Planning Implementation Evaluation The Nursing Process in Patient-Centered Pharmacotherapy Assessment - systemic validation and documentation of information - made throughout the nsg process - provides basis for diagnosis The Nursing Process in Patient-Centered Pharmacotherapy Assessment Subjective Data – described by the patient Current hx history Patient symptoms Current medications Past hx history Patient’s environment The Nursing Process in Patient-Centered Pharmacotherapy Assessment Objective Data – signs that are measured and detected by another person physical health assessment lab tests and dx tests The Nursing Process in Patient-Centered Pharmacotherapy Factors of nonadherence: forgetfulness family problems knowledge deficit language barriers side effects cost low self-esteem anxiety depression lack of motivation lack of trust in the hx care systems The Nursing Process in Patient-Centered Pharmacotherapy Nursing Diagnosis – based on the analysis of the assessment data - actual problem or risk factors - facilitates the development of an individualized care plan for each patient The Nursing Process in Patient-Centered Pharmacotherapy Common Nsg Dx: Pain related to hesitancy in taking prescribed pain medication because of fear of addiction Acute confusion related to adverse reaction to medication Ineffective health maintenance related to not receiving recommended preventive care Deficient knowledge related to effects of anticoagulant medication on clotting mechanism The Nursing Process in Patient-Centered Pharmacotherapy Common Nsg Dx: Noncompliance related to forgetfulness Risk for injury related to side effects of drug Ineffective self-health management related to lack of finances or health care coverage to purchase medications Readiness for enhanced knowledge related to medication schedule and medication side effects The Nursing Process in Patient-Centered Pharmacotherapy Planning – characterized by goal setting - with time frame for re-evaluation Qualities: Patient centered Clearly states the expected change: realistic, measurable, with reasonable deadlines Is acceptable to both patient and nurse Is shared with other health care providers and with patient’s family or caregiver Identifies components for evaluation The Nursing Process in Patient-Centered Pharmacotherapy Implementation and Nsg Interventions: - Nurse provides education, medication administration, patient care, other interventions The Nursing Process in Patient-Centered Pharmacotherapy Patient teaching: readiness to learn ongoing, complex, multifaceted process, dynamic interaction focused on health promotion; specific skill tailored to the patient’s interest and level of understanding sensitive to patient’s motivation to learn, attention span, level of frustration active listener and observer The Nursing Process in Patient-Centered Pharmacotherapy Inclusion of a family member: act as a psychological support actually administer all or part of therapy observe effectiveness and S/E implement other changes or preparation The Nursing Process in Patient-Centered Pharmacotherapy Topics: General - adherence (relapse; ineffectiveness) frequency, dose, time of the day pregnancy laboratory tests Self-administration – psychomotor skills; abilities re-assessing motor skills prescribed route; demonstration; return demo written instructions teach another person as back-up The Nursing Process in Patient-Centered Pharmacotherapy Topics: Diet – food to include and avoid Side effects – report unusual symptoms instructions to minimize S/E change in color of urine or stool, orthostatic hypotension Cultural considerations The Nursing Process in Patient-Centered Pharmacotherapy Evaluation – determines how well goals are obtained - if not met, collaborate with the patient or family and determine reasons Safety and Quality in Pharmacotherapy Safety and Quality in Pharmacotherapy Safety and Quality in Pharmacotherapy “Five-Plus-Five Rights of Medication Administration” The right patient Right drug Right dose Right route Right time Safety and Quality in Pharmacotherapy “Five-Plus-Five Rights of Medication Administration” Right assessment Right documentation Patient’s right to education Right evaluation Patient’s right to refuse Safety and Quality in Pharmacotherapy Safety and Quality in Pharmacotherapy Right patient – two forms of identification before administration of medication Nsg. Implications: Verify the patient by checking patient’s identification bracelet Distinguish between two patients with the same first or last name; warnings Coded ID bracelets Safety and Quality in Pharmacotherapy Right drug– must be countersigned by attending or staff physician - use barcode if with EHR then validate time, date, medication - handwritten prescriptions on tamperproof pad Telephone order/ Verbal order – “read back” and cosigned by the HCP within 24 hrs (RN) Safety and Quality in Pharmacotherapy Electronic health record – entered into the patient’s record, electronically signed, sent to the pharmacy - decreases medication errors by eliminating transcription errors - added speed and safety feature CPOE – computerized physician order entry Safety and Quality in Pharmacotherapy Types of Medication Orders: - Stat order - Single order - Standing order - PRN order Safety and Quality in Pharmacotherapy Components of a drug order: Patient’s name Date and time the order is written Drug name (generic) Drug dosage Route of administration Frequency and duration of administration Any special instructions HCP signature Signature of staff taking TO or VO Safety and Quality in Pharmacotherapy -should not be administered if order is incomplete -clarify in a timely manner; document conversation -nurse is liable for drug administered Ex. 8/28/24 1010H Furosemide (Lasix) 40mg PO daily Signature Safety and Quality in Pharmacotherapy How to avoid drug error: Read label three times 1. at the time of contact with the drug bottle 2. before measuring the drug 3. during administration of drug Safety and Quality in Pharmacotherapy Nsg Int: Identify the patient correctly Nurse should be well versed in the px’s hx (labs) Check if medication order is complete Know px’s allergies Know the reason why patient is to receive medication Check label three times before administration Know the date the medication was ordered and end date Safety and Quality in Pharmacotherapy Automatic stop orders - institutional - controlled drugs to renew every 48hours -antibiotics to renew every 7th or 14th day -cancellation of medications when px goes to surgery Safety and Quality in Pharmacotherapy Right dose - Verification of the nurse that the dose administered is the amount ordered and is safe - Based on physical status, renal and hepatic fxn, weight Safety and Quality in Pharmacotherapy DRUG DISTRIBUTION SYSTEMS Floor or Ward stock drug method – dispensed to all px on the same containers Individual prescription order system – 3 to 5 day supply for an individual patient Unit dose method – drugs are individually wrapped and labeled for single doses for each patient Computer-controlled dispensing system – with security code and password Safety and Quality in Pharmacotherapy Safety and Quality in Pharmacotherapy Right Time – time prescribed dose is ordered to be administered - To maintain therapeutic level - Military time to lessen errors Nsg Int: Administer at specified time (per agency) Administer drugs affected by food 1hr before or 2hrs after Safety and Quality in Pharmacotherapy Administer meds that can irritate stomach with food Adjust the med schedule to fit patient’s lifestyle, activities, tolerances, preferences, if possible Check whether patient is scheduled for any diagnostic procedures that contraindicate administration Check the expiration date Administer antibiotics at even intervals Patients for dialysis should not be given antihypertensive drugs prior to procedure. Safety and Quality in Pharmacotherapy Right route – for appropriate absorption Oral: liquid, elixir, suspension, tablet, pill, capsule Sublingual: under the tongue Buccal: between gum and cheek Via feeding tube Topical: applied to the skin Inhalation: aerosol sprays Instillation: nose, eye, ear Suppository: vaginal or rectal Parenteral: intradermal, subcutaneous, intramuscular, intravenous, intraosseous Safety and Quality in Pharmacotherapy Nsg Int: Assess patient’s ability to swallow; make sure not NPO Do not crush or mix medications without consulting pharmacist Do not mix with infant’s formula feeding If must be mixed, explain to the patient Use aseptic technique when administering drugs Administer at appropriate sites for the route Stay with the patient until oral drugs have been swallowed Safety and Quality in Pharmacotherapy Right assessment - requires collection of appropriate data before administration of the drug - VS, laboratory reports Safety and Quality in Pharmacotherapy Right documentation – requires the nurse to immediately record appropriate information name of the drug dose route time and date nurse’s initial and signature *patient’s response (verbal and physiologic) Safety and Quality in Pharmacotherapy Right to education – patients receive accurate and thorough information about the medication; informed consent Patient teaching: therapeutic purpose skill of administration possible side effects expected result dietary restrictions laboratory test result monitoring Safety and Quality in Pharmacotherapy Right evaluation – appraisal of a drug’s therapeutic and adverse effects; effectiveness Right to refuse – determine reason for refusal and take actions to facilitate administration - documented and follow-up Safety and Quality in Pharmacotherapy Nurse’s Rights When Administering Medication Right to complete and clear order (HCP) Right to have the correct drug, route and dose dispensed (pharmacist) Right to have access to information (formulary) Right to have policies to guide safe medication administration (policies and guides) Right to administer medications safely and to identify problems in the system (advocate in the hx care setting) Right to stop, think and be vigilant when administering medications (Safety) Safety and Quality in Pharmacotherapy Medication safety – freedom from accidental injury from medications Medication error – any preventable event that may cause or lead to inappropriate medication use or harm to a patient Safety and Quality in Pharmacotherapy Increase in the number of drugs available Violation of the rights of nsg medication administration Lack of drug knowledge Overworked Memory lapses Lack of standardization Transcription, dispensing, delivery problems Distractions Inadequate monitoring Inadequate px history Safety and Quality in Pharmacotherapy Medication error: administration of wrong medicine or IV fluid incorrect dose or rate administration to the wrong patient incorrect route incorrect schedule administration of a known allergic drug discontinuation of a medicine or IV fluid Safety and Quality in Pharmacotherapy Avoiding medication errors: Use of barcode List of acceptable abbreviations Use of black box or boxed warning Medication reconciliation Safety and Quality in Pharmacotherapy Abbreviations: ad – right ear KVO – keep vein open as – left ear NGT – nasogastric tube au – both ears od – right eye ID – intradermal os – left eye IM – intramuscular ou – both eyes IV – intravenous PO – by mouth IVPB – intravenous piggyback Safety and Quality in Pharmacotherapy Abbreviations: AC – before meals q - every Ad lib – as desired q2h – every 2 hours BID – twice a day q4h – every 4 hours HS – hour of sleep q6h – every 6 hours NPO – nothing by mouth q8h – every 8 hours PC – after meals STAT – immediately (statim) PRN – whenever necessary TID – three times a day (pro re nata) Safety and Quality in Pharmacotherapy Medication/Drug Reconciliation – process of comparing a patient’s medication orders to all of the medications that the patient has been taking Transition points: hospital admission intrahospital transfer discharge Safety and Quality in Pharmacotherapy Sharps Safety – sharps disposal High-alert medications – more serious consequences LASA – look-alike and sound-alike drug names ephedrine epinephrine humalog humulin Tall man – safety strategy to reduce confusion for computer listing and labelling rispiriDONE ropiniROLE  Ephedrine and epinephrine are both adrenergic agonists but differ in their uses and mechanisms: o Ephedrine: Used to treat low blood pressure and as a decongestant; works indirectly to boost adrenaline effects. o Epinephrine: Used in emergencies like allergic reactions or cardiac arrest; works directly to stimulate the heart and open airways.  Humalog and Humulin are both types of insulin but differ in their onset and duration of action: o Humalog: Fast-acting insulin used before meals to quickly lower blood sugar. o Humulin: Insulin that comes in short-acting or longer-acting forms, used to manage blood sugar over a longer period. Guidelines for Correct Administration of Medications 1. Wash hands before preparing medications. 2. Check for drug allergies; check the assessment history and Kardex. 3. Check medication order with health care provider’s orders, Kardex, medicine sheet or medicine card. 4. Check label on drug container three times. 5. Check expiration date on drug label, card and Kardex; use only if date is current. 6. Recheck drug calculation of drug dose with another nurse as needed or by agency policy. 7. Verify doses of drugs that are potentially toxic with another nurse. Guidelines for Correct Administration of Medications 8. Pour tablet or capsule into the cap of the drug container. With unit dose, open packet at bedside after verifying patient identification. 9. Pour liquid at eye level. The meniscus (lower curve of the liquid, should be at the line of desired dose. 10. Dilute drugs that irritate the gastric mucosa or give with meals. ADMINISTRATION 11. Administer only drugs that you have prepared. Do not prepare medications to be administered by another person. 12. Identify the patient by ID band. 13. Offer ice chip to numb the patient’s taste buds when giving bad- tasting drugs. Guidelines for Correct Administration of Medications 14. When possible, give bad-tasting medications first, followed by pleasant-tasting liquids. 15. Assist the patient to an appropriate position, depending on the route of administration. 16. Provide only amounts and kinds of liquids allowed on the diet. 17. Stay with the patient until the medications are taken. 18. Administer no more than 2.5 to 3ml of solution IM at one site. Infants receive no more than 1ml IM and SQ. Do not recap. 19. When administering drugs scheduled at the same time to a group of patients, give drugs last to patients who need extra assistance. Guidelines for Correct Administration of Medications 20. Discard needles and syringes in appropriate containers. 21. Drug disposal is dependent on agency policy or law. Discard in the sink or toilet. Controlled substances should be returned to the pharmacy. Some needs witness during disposal. 22. Discard unused solutions from ampules. 23. Appropriately store unused stable solutions from open vials. 24. Write date and time opened and your initials on the label. 25. Keep narcotics in a double-locked drawer or closet. Medication carts must be locked at all times. 26. Keys to the opioid cabinets must be with the nurse always. Guidelines for Correct Administration of Medications 27. Keep opioids in a safe place. 28. Avoid contamination of one’s own skin or inhalation to minimize chances of allergy. RECORDING 29. Report drug error immediately to the patient’s HCP and to the nurse manager. 30. Complete an incident report. 31. Charting: drug, dose, time, route, initials. 32. Record effectiveness and results of medications (PRN). 33. Record drugs promptly (STAT). Guidelines for Correct Administration of Medications 34. Report to HCP and record drug that were refused and reason for refusal. 35. Record amount of fluid taken with medications on I&O chart. Medication Administration Self-administration of medication (SAM) – home and community-based settings - patients are responsible for taking their medication accordingly Forms and Routes for Drug Administration Routes: Sublingual Nasogastric, gastrostomy tubes Buccal Suppositories Oral Parenteral Transdermal Topical Instillation Forms and Routes for Drug Administration Tablets and capsules – most common, less expensive, convenient - not given to patients who are lacking in gag reflex, comatose - do not mix with large amount of food, beverage, contraindicated food, infant formula - enteric-coated and timed-release must be swallowed whole - Be aware of medications that should never be cut in half - Administer irritating drugs with food Forms and Routes for Drug Administration Tablets and capsules - Administer drugs on an empty stomach if food interacts with food - Drugs given sublingually and bucally should remain in place until fully absorbed - Encourage use of child-resistant caps Forms and Routes for Drug Administration Liquids Elixirs – sweetened hydroalcoholic liquids (no shaking) Emulsions – mixture of two liquids that are not mutually soluble Suspensions – liquids in which particles are mixed but not dissolved - Read whether needs shaking or not - Meniscus to measure desired dose - Most needs refrigeration when reconstituted Forms and Routes for Drug Administration Transdermal – stored in a patch placed on the skin and absorbed through skin having systemic effect (1980s) - More consistent blood levels than oral and injection forms - Should be rotated to different sites; area thoroughly cleansed to prevent overdosing - Wash hands and wear gloves to prevent transfer of medication - Use patches with lower dosage rather than cutting Forms and Routes for Drug Administration Topical – applied to the skin with glove, tongue blade, cotton-tipped applicator - Apply to clean, dry skin; do not contaminate container - Gloves and applicators that come in contact with a patient should not be reinserted into the container. Forms and Routes for Drug Administration Instillations – liquid medications usually administered as drops, ointments, sprays Eye ointment – lying down or sitting; look at ceiling; apply at least 1/4inch; close for 2 to 3mins Eardrops – room temperature; down and back for children; up and back for adults Nose drops and sprays – tilt back; 5MINS AFTER SPRAY Forms and Routes for Drug Administration Inhalations MDI (metered-dose inhalers) – handheld that delivers medicine to the lower respiratory tract - with counter - teach correct use and cleaning Spacers – used to enhance delivery of medication from MDI Nebulizer – device that changes a liquid medication into a fine mist or aerosol that has the ability to reach the lower, smaller airways Forms and Routes for Drug Administration Forms and Routes for Drug Administration Nasogastric and gastrostomy tubes - Check placement - Replace aspirated gastric fluid - Pour drug into syringe; release slowly - Flush tubing according to policy - Clamp tube and remove syringe Forms and Routes for Drug Administration Suppositories Rectal: for local and systemic absorption -refrigerate; lubricate; privacy - explain; wear gloves; left side-lying; breathe through mouth - remain lying for 20mins Vaginal: lithotomy position Forms and Routes for Drug Administration Parenteral – safety; bypass first-pass effect intradermal – allergic reaction; 24 to 72hrs PPD subcutaneous – slower onset than IM intramuscular – muscle size; minimal nerves and vessels z-track – prevents leaking back; gluteal intravenous intraosseous – bone marrow;