Pharmacology and the Nursing Process in LPN Practice PDF

1 Pharmacology and the Nursing Process in LPN Practice LEARNING OUTCOMES 1. Explain how licensed practical or vocational nurses (LPNs/VNs) use the nursing process in practicing safe drug administration. 2. Compare the differences between subjective and objective data relating to drug administration...

1 Pharmacology and the Nursing Process in LPN Practice LEARNING OUTCOMES 1. Explain how licensed practical or vocational nurses (LPNs/VNs) use the nursing process in practicing safe drug administration. 2. Compare the differences between subjective and objective data relating to drug administration. 3. Describe the specific actions involved in using the nursing process to safely give drugs. 4. List specific nursing activities related to assessing, planning, implementing, and evaluating the patient's response to drugs. 5. Describe each of the nine rights of administration as essential components of safe drug administration. KEY TERMS 9 Rights of Drug Administration (p. 5) A series of nursing actions to protect the patient from drug error. adverse effect (advurs′ ē-fekt, p. 9) A drug effect that is more severe than expected and has the potential to damage tissue or cause serious health problems. It may also be called adverse effect, toxic effect, or toxicity and usually requires an intervention by the prescriber. assessment (ă-SĔS-mĕnt, p. 2) The first step of the nursing process that involves gathering information about the patient that will be used in planning care. contraindication (con-tra-in′dikā′shən, p. 5) A health-related reason for not giving a specific drug to a patient or a group of patients. diagnosis (dĭ-ăg-NŌ-sĭs, p. 4) A name (or label) for the patient's disease or condition. expected side effects (p. 9) Unintended but not unusual effects of the drug that occur in many people taking the drug; they are usually mild and do not require that the drug be stopped. evaluation (ĭ-văl-ū-Ā-shŭn, p. 9) The process of determining the right response looking at what happens to the patient when the nursing care plan is put into action. It is an appraisal of the treatment effectiveness. 25 healthcare setting (HĔLTH-kār SĔT-tĭng, p. 2) Any setting in which the LPN/VN practices nursing. identifiers (ī-DĔN-tĭ-fī-rz, p. 6) Information used to reliably prove an individual is the person for whom the drug treatment is intended. Identifiers may be person's full name, their medical record identification number, birth date, or even the telephone number. implementation (ĭm-plĕ-mĕn-TĀ-shŭn, p. 5) The act of carrying out the planned interventions. nursing process (NŬR-sĭng PRŎ-sĕs, p. 2) A system to guide the nurse's work in a logical way. Consists of five major steps: (1) assessment; (2) diagnosis; (3) planning; (4) implementation; and (5) evaluation. objective data (ŏb-JĔK-tĭv DĀT-ă, p. 3) Information that can be seen, heard, felt, or measured by someone other than the patient. planning (p. 4) Using information gathered in the nursing assessment about the patient to set short-term and long-term goals. subjective data (sŭb-JĔK-tĭv DĀT-ă, p. 2) Reports of what the patient says he or she is feeling or thinks. therapeutic effect (thĕr-ă-PŬ-tĭk, p. 9) The intended action of the drug, also known as a drug's beneficial outcome. The LPN/VN's Role and the Nursing Process Licensed practical or vocational nurses (LPNs/VNs) play a vitally important role in providing nursing care for patients and families. In fact, the need for a well-educated LPN/VN workforce is predicted to grow even faster than the average rate of all other occupations. The factors that increase the demand for LPNs/VNs include an aging nursing workforce reaching retirement age, an aging population in general, and an increased number of people who are living with chronic (and complex) illnesses. LPN/VN practice has shifted quite dramatically over the past decades from the time when most graduates practiced in acute care settings (hospital-based care) to today when graduates practice in a wide variety of long-term and community-based settings. LPNs/VNs practice in nursing homes, assisted living agencies, outpatient clinics, home health agencies, hospices, and rehabilitation centers, to name just a few. No matter the setting, as an LPN/VN, you will share a responsibility with registered nurses (RNs) and other members of the healthcare team to provide safe, quality, and cost-effective care. Wherever you choose to practice, it is likely that drug administration will be a significant part of your role. In fact, a recent survey of new LPN/VNs revealed that about 40% of work hours were related to providing care relating to giving drugs and to monitoring patients who are receiving drugs, including parenteral therapies. Before we begin discussing specific drugs, we will review the nursing process as it relates to drug administration. Although you may be familiar with the nursing process, we are going to focus on how you will use the nursing process as you safely give drugs to patients in a variety of settings. To review, the nursing process is a system that guides the nurse's work in a logical way (Fig. 1.1). The nursing process 26 consists of the following five major steps: (1) assessment, (2) diagnosis, (3) planning, (4) implementation, and (5) evaluation. FIG. 1.1 The nursing process. Assessment Assessment is the first step in the nursing process and involves gathering information (also called “data”) about the patient that will be used in planning care. An RN is typically assigned as the staff member who must perform the initial full assessment for each patient. As an LPN/VN, you will often make vital contributions to this assessment. This step of the nursing process is important because it gives you initial information as you begin to make a record for developing the plan of care. The first part of assessment relating to drug administration involves gathering information about the patient and the patient's health condition before you give the drugs. When the patient is admitted to the healthcare setting (any setting in which LPN/VNs practice nursing), you can obtain that information by talking to the patient (or his or her caregiver if necessary), checking the patient closely for signs and symptoms of illness, viewing past medical records, or reviewing information the patient may bring with him or her. Ask carefully about any current health problems, a history of illnesses and/or surgeries, and drugs (including over-the-counter and herbals) taken both now and in the past. This information is important for all team members and helps everyone to plan the patient's care. Information in the patient's history often directs the nurse and the physician to look for certain physical signs of illness that may be present. Information you gather through assessment falls into two groups: subjective data and objective data. Subjective data are reports of what the patient says he or she is feeling or thinks. For example, if a patient reports feeling nauseated after taking a drug, you must accept the patient's word. You cannot see, hear, or feel the patient's 27 nausea—that is why it is subjective. A patient may state that he or she has trouble breathing. Although you may observe rapid breathing, the degree of difficulty the patient feels cannot be measured. Information is subjective if you have to rely on the patient's words or if the symptoms cannot be felt by anyone other than the patient. In such cases you would report, “The patient states that…” Other examples of subjective data that you may learn about from a patient interview are: • the chief problem according to the patient (in the patient's own words) • the patient's belief about what caused the problem • the patient's description about what relieves the problem • the patient's report of the severity of the problem Objective data are data that can be seen, heard, felt, or measured by someone other than the patient. These include information obtained when the healthcare provider performs a physical examination or orders laboratory tests, x-rays, and other diagnostic tests. Typically the RN or physician will conduct a comprehensive physical assessment. As an LPN/VN, it will be important to assess vital signs (respiratory rate, pulse, blood pressure, weight, height, temperature), physical findings based on careful observation, auscultation (listening with the stethoscope), and light palpation as appropriate for your clinical setting and your state Nurse Practice Act. Other examples of objective data include: • presence of edema • quality of a cough • percentage of foods eaten at a meal • measures of intake and output It is especially important to gather subjective and objective assessment data when the patient is first seen or on admission to the healthcare setting. This provides initial information that can be used as a baseline for comparison as care progresses. In addition to the physical examination, it is important to gather a good patient history. Thus asking questions and listening carefully to the patient may be just as important as the physical examination or the results of laboratory tests. Because the LPN/VN is often with the patient, he or she will play a very important role in continuing to listen to what the patient says and report new information to the other healthcare team members. The nurse may not always be the one gathering the subjective and objective data; however, the nurse and everyone else on the healthcare team should learn whatever information they can from the chart, the physician, the family, and other team members, and use that information to plan the patient's care. Understanding the difference between subjective and objective information will help you in reporting, 28 or charting, the information. Based on our previous example, if the patient reports nausea (subjective information), your charting should say, “The patient reports nausea,” rather than “The patient is nauseated,” because you do not objectively see nausea. On the other hand, if the patient vomits (objective information), you will record the time, color, and amount. Much of your role in assessing can be reporting data you collect to the RN (or to other members of the healthcare team). The primary role you play in assessing the patient is defined by your state Nurse Practice Act, which lists what actions LPN/VNs may and may not do. In addition, your role may vary according to your healthcare setting's policies and procedures. Factors to Consider in Assessing the Patient Certain information is very helpful in planning the care of the patient who is receiving drug therapy. As mentioned earlier, the baseline nursing assessment is conducted at the time of the patient's admission to the healthcare setting. One important part of the assessment is the patient's drug history. The patient is typically the best source; however, you may also include reports from caregivers (such as the spouse, close relatives, or friends) and past medical records (often in the electronic medical record [EMR]). When asking about the patient's drug history, you will want to make assessments in the following areas: 1. Symptoms, signs, or diseases that explain the patient's need for a drug (such as high blood glucose levels, high blood pressure, or pain) 2. The names and, when possible, dosages of all the drugs the patient is taking, for example: • prescription drugs (patients often forget to mention birth control pills as well as implanted birth control measures in this category) • over-the-counter drugs such as aspirin, vitamins, laxatives, cold and sinus preparations, and antacids • alcohol or street drugs used for recreational purposes (such as marijuana or cocaine) • alternative therapies such as herbal agents or nutritional supplements 3. Any problems that the patient has had with drug therapy, for example: • allergies: include the name of the drug and the type of the reaction that the patient experienced (in other words, whether it was a mild or severe effect) • diseases that may prohibit or limit use of some drugs (such as sickle cell disease, glucose-6-phosphate dehydrogenase deficiency, history of drug addiction, or immune deficiencies) Assessments for all of these areas are important because this information can help prevent drug interactions or complications of drug therapy. You will also use this information as you monitor your patient's response and any changes in patient condition or status that may influence drug therapy during the time the patient is in the healthcare setting. This will help you determine whether the drug is helping the 29 patient. Memory Jogger Nursing assessment is using your observational, questioning, and listening skills to learn information about the patient that can be used to ensure you are safely giving drugs. Diagnosis Once the assessment information has been collected, the nurse and other healthcare team members must make a diagnosis (a name [label] for the patient's disease or condition). The physician will decide the medical diagnoses. The RN will determine the nursing diagnoses. Although you will come to some decisions about how sick the patient is and how carefully you need to monitor him or her, your role does not include the development of formal diagnoses. Nevertheless, you will use knowledge about the diagnoses as you contribute to the plan of care. Examples of follow-up questions you will need to ask relating to giving drugs include: • What are the major health-related problems of this patient? • What drugs is the patient likely to require? • What special knowledge or equipment is required in giving these drugs? • What special concerns or cultural beliefs does the patient have? • How much does this patient understand about the treatment and drugs prescribed? • What factors affect the patient's ability to care for himself or herself? The answers to these questions will (1) help you contribute to the goals of nursing care, (2) affect strategies you will use to care for the patient, and (3) tell you what type of patient teaching will be needed. Answering these questions may be more challenging with children, older adults, or people whose language or culture is different from yours. However, just as a physician must have the correct diagnosis to prescribe the right treatment, finding the correct answers to these questions helps you to plan the best care for the patient. Planning Based on the data you help collect, the medical and nursing diagnoses are made, goals are set, and nursing care plans are written. As a member of the healthcare 30 team, the LPN/VN will be able to assist with the planning step. The nursing care plan involves a collaboration with nurses and the patients or caregivers. Using the information gathered in the assessment about the patient's history, medical and social problems, risk factors, and how ill the patient may be, goals will be set on either a short-term or a long-term basis. For example, short-term goals may be written that “the patient will describe pain at a level of 3 or below on a scale of 0 to 10, 30 minutes after receiving a drug for pain.” An example of a long-term goal would be, “The patient will show how to rotate injection sites for using his or her insulin pen by the time of discharge.” Memory Jogger When collecting the drug history, make sure to include the patient's use of over-thecounter drugs, such as herbal and nutritional supplements, because these may interfere with prescription drugs. Drug Orders and the Nursing Care Plan Physicians, nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, and physician assistants may write drug orders according to individual state laws. Large hospitals may have a staff hospitalist, a physician or nurse practitioner who practices in the hospital, to oversee care for all patients. Teaching hospitals may have resident doctors who are still in educational programs. Once the drug is ordered, the nurse must verify that the order is accurate. This is usually done by checking the drug administration record or electronic medical record against the original order. You will need to learn and follow the procedures of the agency where you work when checking drugs and drug orders. In all care environments you must carefully check each time you give a drug. This is essential to maintaining patient safety and minimizing the risk for error or adverse effects. The nurse must also apply knowledge about the drug to the specific drug order to determine whether the drug and the dose ordered seem to be correct. No part of the order or the reason for giving the drug should be unclear. (Chapter 2 lists what information is required for a clear and legal drug order.) Any questions about whether a drug is appropriate or safe for that patient must be answered before the drug is given. The electronic medical record may alert the nurse if there is a problem with the order. However, good clinical judgment in carrying out the drug order is very important. If you determine that (1) any part of the order is incorrect or unclear, (2) the patient's condition would be made worse by the drug, (3) the person ordering the drug may not have had all the information needed about the patient when drug therapy was planned, or (4) there has been a change in the patient's condition and a question has arisen about whether the drug should be given, then the drug should be withheld (that is, not given) until the question can be answered and the healthcare provider called. If you believe there is a problem with the drug order and the provider cannot be contacted or does not change the order under question, notify the charge nurse and the nursing supervisor as soon as possible. Most hospitals have clear policies about whom to contact, how to report this problem, and what to do next. 31 Once you have the drug order, and have decided to give the drug, include in your plan those patient problems that may increase the risk for issues relating to the drug's side effects. For example, a patient who has poor vision may have a risk for falling in an unfamiliar hospital or nursing home setting. This will be important if you are giving a diuretic and the patient needs to go to the bathroom frequently. You will need to plan ahead so that the patient can safely get to the bathroom. The importance of these problems may change over time as the patient's condition changes. Ongoing communication between nurses and the healthcare team is important to maintain safe, quality, and cost-effective patient care. Factors to Consider in Planning to Give a Drug Planning to give a drug involves four important steps: 1. Know the reason you are giving the patient the drug. (In other words, what is this drug supposed to do for the patient?) 2. Learn specific information about the drug including: • the major action of the drug; • negative side effects that may develop; • the usual dosage, route, and frequency; • situations in which the drug should not be given (contraindications); and • main drug interactions (in other words, the possible influence of another drug given at the same time). 3. Plan for special storage or procedures, techniques, or equipment needs. • Does the solution need to be shaken before giving? • Should the drug be refrigerated? • Do you need a specific syringe (such as an insulin syringe)? • What special techniques are necessary for giving the drug, such as using an inhaler or not applying pressure to the site after giving certain injectable drugs? 4. Develop a teaching plan for the patient, including: • what the patient needs to know about the drug's action and side effects, • what the patient needs to know to take the drug correctly, and • what the patient needs to report to the nurse or physician if there are any problems. As you develop your plan, make sure to use the information you gathered in your assessment and your knowledge about the drug. You will use this information as you prepare to implement your plan. Whether to give the drug will be dependent on your assessment, your knowledge, and your professional judgment. Top Tip for Safety Drug Orders 32 Make certain that you understand each part of the drug order. Do not give the drug if you have a question about any part of the order. The planning step of the nursing process is also the time to: • Get any special equipment you need to give the drug (such as intravenous [IV] infusion pumps, alcohol wipes, or nebulizers). • Review any special procedures you will need to give the drug (such as the Z-track injection technique or for giving a rectal suppository). All of this information can be documented in the nursing care plan into the paper or electronic medical record so that other team members can see the plan. Implementation Implementation involves carrying out your plan of care as you safely give the drugs to the patient. In planning care, you learned why each drug was ordered, the drug's actions, and how to safely give the drug. For example, if you are giving an angiotensin-converting enzyme inhibitor (see Chapter 8) to a patient with high blood pressure, you will need to check the patient's blood pressure before giving the drug. On the other hand, if you are planning to give the ordered penicillin antibiotic (see Chapter 5) and you notice the patient has a red rash on his or her chest and arms, you would hold the next dose of the drug until you have reported the rash to the healthcare provider because it may indicate an allergic reaction. Then after you have carried out the plan, you will record in the patient's chart or electronic medical record that you have given the drug. The 9 Rights of Drug Administration A major strategy for giving drugs to patients is called the 9 Rights of Drug Administration. There are nine commonly recognized rights of drug administration that the nurse must always keep in mind (Box 1.1). Box 1.1 The 9 Rights of Drug Administration • The right patient—use at least two identifiers. • The right drug—check the drug label at least three times. • The right dose—make sure that you use the right amount of the drug; doublecheck the dose. 33 • The right route—never change the route of administration without an order. • The right time—make sure that the drug has not been given recently or should be given at a different time of day. • The right reason—does this make sense for this patient? Know your patient and the drug. • The right documentation—document after you have given the drug, never before. • The right response—how is the patient responding to the drug? Does it work? • The right to refuse—patients have the right to refuse; make sure to ask the patient to clarify his or her reason, provide good patient teaching, and document. You may have heard nurses in the clinical setting discuss the importance of the “five rights,” “six rights,” or “eight rights.” Over time, nursing has continued to emphasize those essential components of safe drug administration and added more rights. For our purposes the nine rights ensure that you identify the right patient and give the right drug with the right dose using the right route at the right time for the right reason. Then you use the right documentation to record that the dose has been given. You will then monitor the patient to assess the right response. The final right is that patients do have the right to refuse the drug. You might wonder: How can I remember nine things? A runner who really enjoyed racing in 15K races (9.3 miles) said that he liked them the best because he could divide them into three 5Ks (3.1 miles) so it seemed easier. You can do the same with the nine rights. We will review each right and explain the reason these are essential for safe, quality, and cost-effective care. Memory Jogger The 9 Rights of Drug Administration (Three at a Time) • Right patient, right drug, right dose • Right route, right time, right reason • Right documentation, right response, right to refuse The Right Patient Before you give any drug, you need to make sure that you identify the right patient. The National Patient Safety Goals claim that the purpose of this is to: (1) reliably identify the individual as the person for whom the treatment is intended, and (2) match the treatment to the person. To properly identify the patient, you will use at least two identifiers. Identifiers are information that is used to reliably prove an individual is the person for whom the drug treatment is intended. Identifiers may be the person's full name, his or her medical record identification number, birth date, or even telephone number. These may be compared with the patient's identification 34 bracelet (wristband) if appropriate. Healthcare agencies may specify the main identifiers to be used in the setting and/or use a bar code system to scan the drug to the wristband. For patients who are alert and oriented, asking them their full name and birthdate, and comparing with the medical record number is very clear. On the other hand, for those who are hard of hearing, confused, very young or very old, or are critically ill, make sure to compare the name, birthdate, or medical record against the patient's wristband (Fig. 1.2). Best practice is for you to directly ask the patient to “tell me your full name.” This is much safer than asking the patient, “Are you Joe Jones?” A patient who is confused may not understand the question and say yes or no regardless of whether that is his correct name. In the hospital setting, never give a drug to a patient who is not wearing a wristband. Some long-term care settings use photographs of patients to assist the nurse in identifying patients who might be confused. Never identify the patient solely by the room or bed number. FIG. 1.2 Nurse checking the patient's wristband for identification. (From Hoffmann Wold G: Basic geriatric nursing, ed 5, St. Louis, 2012, Mosby.) The Right Drug Each drug that is prescribed for the patient has a particular intended action. You will need to make sure that you give the right drug. You will need to carefully compare the drug order with the drug label. Do not just assume that the correct drug has been sent by the pharmacy. Be sure that the drug is in the correct form prescribed, because some drugs can come in multiple forms (e.g., tablets, capsules, or syrup). Also, many drugs have names that sound or look nearly the same as the names of other drugs (sometimes called “look-alike, sound-alike drugs”). The Institute for Safe Medication Practices (ISMP) has a List of Confused Drug Names (Table 1.1). In addition, the US Food and Drug Administration and ISMP recommend the Tall Man lettering system to reduce confusion for look-alike drug names (Table 1.2). For example, Lamisil (a brand name 35 for an antifungal) is written as LamISIL. This helps highlight the “ISIL” so the nurse does not confuse it with Lamictal (an antiseizure drug), written as LaMICtal. The Tall Man lettering system has been embraced by healthcare agencies as one more strategy to reduce drug errors. Table 1.1 Examples From Institute for Safe Medication Practices Common Confused Drug Names DRUG NAME CONFUSED DRUG NAME DRUG NAME CONFUSED DRUG NAME Aciphex Adderall Allegra Benadryl Bextra captopril Cozaar Accupril Inderal Viagra benazepril Zetia carvedilol Zocor Diprivan Flonase Lantus Lexapro Microzide Paxil Pyridium Ditropan Flovent Lente Loxitane Micronase Plavix pyridoxine Brand name drugs always start with a capital letter. Generic drug names always start with a lowercase letter. Table 1.2 Examples From Institute for Safe Medication Practices List of Drug Names With Tall Man Letters DRUG NAME WITH TALL MAN CONFUSED DRUG LETTERS NAME DRUG NAME WITH TALL MAN CONFUSED DRUG LETTERS NAME busPIRone chlorproMAZINE glipiZIPyDE NIFEdipine* cefTRIAXone KlonoPIN PriLOSEC SOLU-Medrol SandIMMUNE SEROquel ZyPREXA FLUoxetine* HumaLOG hydroOXYzine bupropion chlorproPAMIDE glyBURIDE niCARdipine ceFAZolin cloNIDine PROzac Solu-CORTEF SandoSTATIN SINEquan ZyrTEC PARoxetine* HumuLIN hydrALAZINE Brand name drugs always start with a capital letter. Generic drugs typically start with lowercase letters. NOTE: Some generic drug names incorporate tall man letters. Generic drugs that start with tall man letters are identified with an asterisk. Drugs may come individually wrapped in a unit-dose system package, as a prescription filled for one person, or in rare cases taken from a unit's stock drugs. Sometimes the drug label has a bar code that is scanned by a computer. However it is packaged, you must read the drug label at least three times. Top Tip for Safety Read the drug label three times! 1. Before taking the drug from the unit-dose cart or storage area 2. Before preparing or measuring the prescribed dose of drug 3. Before opening the drug at the time you give it to the patient The Right Time The drug order should say when the drug and how often the drug is to be given. In many situations you will work with the RN (and/or pharmacist) to determine the 36 right time. Most healthcare agencies have guidelines that specify what time drugs will be given when they are ordered (e.g., “drugs given once a day are given at 9:00 a.m.”). You must be familiar with your agency guidelines for general times of administration. Nevertheless, it will be important for you to report if the drug information suggests timing of the drug that conflicts with the usual guideline. For example, some statin drugs (given once a day) should be given before bedtime for best effect rather than in the morning. If you have any questions, make sure to notify the RN or the healthcare provider. It is always better to ask the question than to risk the mistake. To be effective, many drugs must be given exactly on schedule day and night to keep the level of drug constant in the body. For example, if a patient is taking warfarin, an anticoagulant, to decrease the risk for blood clots, the drug must be given at the same time every day. Patients with infections should follow a very regular schedule to maintain a consistent level of the drug and decrease the risk for antibiotic resistance. You may need to plan around other patient activities when you give drugs. A patient with a newly diagnosed infection may need a blood culture drawn before starting antibiotic therapy. You may want to hold (wait until later) giving a diuretic in the early morning if the patient is scheduled for an ultrasound so that the patient does not experience urinary urgency while having the procedure. As you go through each chapter on drugs, you will learn more on this topic. Drugs are usually given when there is the best chance for the body to absorb it and the least risk for side effects. This may mean that some drugs should be given when the patient's stomach is empty, and others should be given with food to prevent gastrointestinal side effects. Some drugs require that the patient not eat certain foods. Others do not mix well with alcohol. Antacids interfere with the absorption of a number of drugs; therefore antacids need to be given 2 hours before or 2 hours after taking these drugs. When a patient is taking several drugs, check to ensure that the drugs do not interfere or interact with each other. (For example, some antibiotics may interfere with the action of birth control pills, so a sexually active woman taking both could become pregnant if she does not use another form of contraception.) Whenever you are giving a new drug or one you have never seen before, use your drug references to ensure the timing is correct. Finally, one-time-only, as needed (PRN), or emergency drugs are especially important to confirm regarding the timing. The nurse must be certain that no one else has already given the drug and that it is the appropriate time to give the drug. Narcotics (opioids) are often ordered as “stat” (given within a few minutes of the order) or PRN drugs. Note on the patient's record as soon as possible that you have given a narcotic so that it is clear the patient has been given the drug. (For more information, see Chapter 2.) Box 1.2 lists the main factors to remember in giving a drug at the right time. Box 1.2 Factors to Consider in Giving a Drug at the Right Time 37 • Always make sure to confirm the last time the drug was given to avoid giving too much in too short of a time period. • Understand and follow the rules of your hospital regarding the times to give scheduled drugs. • Check drug references for best times to achieve the best drug absorption and to limit risks for drug interactions with other drugs. • Give drugs at times ordered to help keep blood levels of the drug constant. • Plan drug therapy while keeping in mind other diagnostic and laboratory testing that your patient may be experiencing. Even though it may be tempting if you are on a busy unit, never leave a drug at the patient's bedside for him or her to take later. If the patient cannot take the drug when you bring it to him or her, you can return with the drug later. As a nurse, you must document the time the patient actually takes the drug. If you are not present when the patient takes the drug, you cannot document it. The Right Dose As an LPN/VN, you will want to make sure you are giving the right dose. The amount of drug to be given is typically ordered by the healthcare provider as a dose for the “average” patient. A patient who is older, who has experienced severe weight loss as a result of illness, or who is small or very obese may require changes in the usual dosages. Pediatric patients often have doses ordered based on how much they weigh. Geriatric or older adult patients may be very sensitive to many drugs and may require a change in dosage. Patients with poor liver or kidney function may require changes in dosage necessary for effect. Also, the healthcare provider may order a specific dosage of the drug when treatment begins, but adjust the dose according to changes in the patient's condition. Giving the correct dose of a drug also requires that you use the proper equipment (e.g., insulin must be measured in an insulin syringe), the proper drug form (e.g., oral or rectal, water or oil base, scored tablets or coated capsules), and the proper concentration (e.g., 0.25% versus 0.5% solution for eye drops), and that you accurately calculate the right drug dose. For high-alert drugs (see Chapter 4), many healthcare settings have policies that require two nurses to check any drug dose that must be calculated, particularly for drugs such as narcotics, heparin, insulin, or IV drugs, to reduce risk for error. The Right Route Each drug must be given by the right route. The drug order must state how the drug is to be given (route of drug administration). The nurse must never change routes without obtaining a new order. Although many drugs may be given by different routes, the dose is often different for each route. The oral route is the preferred route if the patient is oriented (awake and able to understand) and can swallow without choking. In some cases, faster delivery or a higher blood level of a drug is needed, so the drug may be given parenterally (e.g., subcutaneously or intravenously; see Chapter 4). There may be special precautions for drugs given through these routes (such as how fast they can be given or in what 38 dosage). Review your drug references to ensure that you are giving the drug correctly. For patients with breathing problems such as asthma, drugs that previously were given orally can now be given via an inhaler. This has decreased the number of side effects by getting the drug right where it is needed: in the lungs. You will need to teach the patient the techniques to achieve the greatest benefit from the inhaler. Other routes that you will see in practice are drugs given as eye drops, eardrops, topical agents, and even as part of shampoos. The most important thing is that you give the right form of the drug for the right route. Top Tip for Safety Make Certain the Patient Takes the Drug Never leave a drug at the patient's bedside for him or her to take later. The Right Documentation Increasingly, electronic health record and charting systems are being used in healthcare settings. Whether the nurse records giving the drug in a paper chart or using an electronic chart, the basics are the same: You will want to make the right documentation. Record the time, route, and site of administration (if parenteral drug) after you have given the drug. It is very important to record this right away (do not delay or “wait until later”). As a tool of communication, failure to record means you did not give the drug. In an emergency or when a drug is used only once or twice, this is very important. The documentation must always list the drug given, the dose, and the time it was actually given (not the time it was supposed to be given). In some offices or clinics where immunizations are given, the policy may require that the lot number listed on the bottle be recorded in the patient's chart. Most charting systems include a place to record the patient's response to the drug. Any patient reports of problems or adverse effects must be noted in the chart and reported immediately to the head nurse and the physician. It is vitally important that you never record drugs that were not given or record them before they are given. If a patient does not receive the drug for any reason, notify the nurse in charge or the healthcare provider according to your healthcare setting policies. Following the rules of your healthcare setting and carefully following the rights of drug administration will reduce the risk for drug error. Should an error be made, talking about it honestly and taking quick action to correct any damage is vitally important to protect the patient from harm. Acknowledging error is an essential, and ethical, part of nursing practice. The Right to Refuse Patients do have the right to refuse the drugs based on the principle of autonomy (right to self-determination). Although we recognize that patients can refuse, it is really important to talk with the patient regarding his or her reasons for refusal. In 39 many cases, the refusals are based on a lack of understanding about the purposes of the drug so that you have the opportunity to teach or clarify information about it. Another example is a patient who refuses a laxative because he or she has diarrhea (clearly a good reason!). Whatever the reason, if the patient refuses after you have answered all of his or her questions, make sure to document the refusal in the medical record. Of note, there may be clinical areas (such as psychiatric units) where patients may be a danger to themselves or to others. In those situations make sure to know your state laws that allow emergency treatment orders. If there is any question, make sure to check with the RN or the healthcare provider. Evaluation Evaluation is the process of determining the right response and looking at what happens to the patient when the nursing care plan is put into action. It is the appraisal of the treatment's effectiveness. Evaluation requires the nurse to watch for the patient's response to a drug, noting both expected and unexpected findings. For example, when antipyretics (drugs that reduce fever) are given, you will take the patient's temperature to determine whether the drug lowered the fever. When drugs are given to reduce blood pressure, you will want to do regular blood pressure checks. For drugs used to reduce pain, you will evaluate whether the drug reduced the patient's pain according to your agency pain scale. Evaluation of what happens when you give a drug helps the healthcare team decide whether to continue the same drug or make a change. Gathering such information is also a part of the continuing assessment of a patient during care that the nurse will record in the patient's chart. Thus the nursing process may be seen as a circle (see Fig. 1.1). For example, the patient's temperature can be part of the evaluation step of the nursing process, but it may also be part of the assessment step when you notice that the patient's temperature remains elevated, indicating that the patient needs a different dose of the drug, a different drug altogether, or some additional treatment measures. Top Tip for Safety Evaluate Response to Drug It is important to watch the patient and look for any signs of improvement or if there are any side effects, adverse effects, or allergic responses. Factors to Consider in Evaluating Response to Drug The nurse checks for three types of responses to drug therapy: therapeutic effects, expected side effects, and adverse effects. Therapeutic effects are seen when the drug does what it was supposed to do. If you understand why the drug is being given (the therapeutic goal of the drug), you will be able to decide whether that goal is being met. For example, if the patient's blood glucose is high and regular insulin is given, you should see a lower blood 40 glucose level when the next blood glucose is checked. If the patient is constipated and takes a laxative, the patient should have a bowel movement. Expected side effects are those unintended but not unusual effects that occur in many people taking the drug; they are usually mild and do not require that the drug be stopped. One example of an expected side effect is the sleepiness that most patients feel when taking an opioid (narcotic) for pain. All drugs have side effects, but not all patients have every side effect listed for any single drug. Always document side effects. Sometimes side effects such as nausea or vomiting may be stopped by decreasing the dosage or by giving the drug with food. Telling the healthcare provider about the side effects helps him or her decide whether the patient should keep taking the drug or it should be stopped. Adverse effects are seen when patients do not respond to their drugs in the way they should or they develop new signs or symptoms. For example, a patient with pneumonia may be given penicillin. Although this antibiotic may be working to control the infection, the patient may develop shortness of breath, which may be an allergic reaction to the drug; in this case the penicillin must be stopped. A patient taking an anticoagulant to prevent blood clots must be closely watched for signs of bleeding or bruising that would indicate that the patient has taken too large of a dose or has a larger-than-expected response to the drug. If you suspect a patient is having an adverse effect, make sure to report to the RN or the healthcare provider immediately. Usually when serious adverse effects occur in response to a drug, the healthcare provider discontinues (stops) the drug. The nurse is the healthcare worker most often with the patient and is in an important position to notice the patient's response to drug therapy. Carefully and repeatedly evaluating the patient and documenting your findings in the patient's medical record is vitally important in the delivery of safe, quality, and cost-effective care. Top Tip for Safety Use the nine rights each and every time you give a drug to a patient! Get Ready for the NCLEX® Examination! Key Points • Use the nine rights each and every time you give a drug to a patient. • Nursing assessment is using your observational, questioning, and listening skills to learn information about the patient that can be used to ensure you are safely giving drugs. • When assessing a patient, always ask carefully about any current health problems, history of illnesses, history of surgeries, and drugs (including OTC and herbals) taken both now and in the past. • Always know why you are giving the patient the drug. • Check the label of each drug you are giving three times to ensure it is the right 41 drug. • Do not give a drug that was made for one route by any other route. • When giving a one-time-only drug, take extra precautions to make certain that it has not already been given by someone else. • Never record drugs that were not given or record them before they are given. • Always use two unique patient identifiers when giving a patient a drug • If a patient refuses to take a drug, clarify the patient's reason and make sure to document the refusal. • All drugs have side effects, but not all patients have every side effect listed for any single drug. • Any questions about whether a drug is appropriate or safe for that patient must be answered before the drug is given. • If you suspect a patient is having an adverse effect, make sure to report to the RN or the healthcare provider immediately. • Never leave a drug at the patient's bedside for him or her to take later. • In the hospital, never give a drug to a patient who is not wearing an identification band. Review Questions for the NCLEX® Examination 1. What is the most appropriate measurement to determine the therapeutic response of an antipyretic drug? 1. Blood pressure 2. Respiratory rate 3. Temperature 4. Radial pulse 2. Which of the following examples would be considered objective data? (Select all that apply.) 1. “I have pain in my abdomen.” 2. Blood pressure is 160/90. 3. Skin is mottled. 4. “I had a lab test last week at my doctor's office.” 5. Child's mother states, “His temperature was 102 degrees before we came to the hospital.” 6. Weight gain of 2 pounds in 4 days. 7. Patient states she has trouble breathing or “catching” her breath. 3. Which of the following would be considered examples of the nine rights? (Select all that apply.) 1. Right patient 2. Right time 42 3. Right room number 4. Right to refuse 5. Right documentation 6. Right reason 4. Which of the following examples would be considered a contraindication? 1. Giving a drug for nausea to a patient who has just vomited. 2. Giving a drug that causes birth defects to a patient who is 12 weeks' pregnant. 3. Giving a drug that may cause dizziness to a patient with high blood pressure. 4. Giving a drug that may cause an increase in heart rate to a patient who has asthma. 5. The LPN/VN is giving a patient her morning drugs due at 9:00 a.m. After you have already prepared the drug, the patient states, “No, I don't want that pill today.” What is your best first action? 1. Tell the patient she has to take the drug because it was ordered by the doctor. 2. Ask the patient to tell you her reason for not taking the drug. 3. Teach the patient why she needs it and give the drug. 4. Ask the patient if she has any questions about the drug. 6. What is considered the best resource for current use of drugs at admission to the healthcare setting? 1. The patient 2. The medical record 3. The caregiver 4. The prescriber 7. The LPN/VN is assessing a patient before giving a drug to manage his blood pressure and notes the blood pressure to be 90/50 mm Hg. What is the nurse's best action? 1. Hold the drug and report to the RN in charge. 2. Give the patient a cup of coffee and give the drug. 3. Come back in 30 minutes and recheck the blood pressure. 4. Tell the patient to walk in the hall and give the drug. 8. What is the best way to check that you are giving the drug to the right patient? 1. Ask the patient's name. 2. Compare the patient with the room number. 3. Check the patient's wristband. 4. Check two unique patient identifiers. 9. Which of the following nine rights should you apply immediately after you give a drug? 1. Right drug 2. Right patient 3. Right documentation 43 4. Right dose 10. Which priority assessment must you make before giving any patient a drug by mouth? 1. Quiz the patient about the action of each drug. 2. Make sure the patient can swallow. 3. Find out whether the patient prefers cold or room temperature liquids. 4. Ask the patient to repeat his or her name and birthdate. 44