Pharmacology and the Nursing Process PDF

Nursing Process in Drug Therapy and Patient Safety KELVIN G. ASIS, RN, MSN What is Nursing Process? Defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. Nursing process is crucial for safe medication administration....

Nursing Process in Drug Therapy and Patient Safety KELVIN G. ASIS, RN, MSN What is Nursing Process? Defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. Nursing process is crucial for safe medication administration. “Crucial”- of the greatest significance in determining an outcome. In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today.  5 Steps  ASSESSMENT  NURSING DIAGNOSIS  PLANNING (GOALS/ OUTCOME CRITERIA)  IMPLEMENTATION  EVALUATION Nursing process draws together all of the aspects of the patient:  Physical  Cultural  Cognitive  Spiritual  Sexual  Financial What its Purpose? 1. To identify the client’s health status and actual or potential health care problems or needs. 2. To establish plans to meet the identified needs. 3. To deliver specific nursing interventions to meet those needs. 4. To apply the best available caregiving evidence and promote human functions and responses to health and illness. 5. To help the nurse perform in a systematically organized way their practice. 6. To establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care  ASSESSMENT  Data collection - Subjective - Objective I. ASSESSMENT  A.) Patient's history  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.  History of Chronic Conditions  It can affect the pharmacokinetics and pharmacodynamics of a drug.  Certain conditions like renal disease, heart disease, diabetes, chronic lung disease may be contraindications to the use of a drug.  These conditions may require cautious use or dose adjustment when administering a certain drug.  History of Drug Use  Prescription drugs, over-the-counter(OTC) drugs, street drugs, alcohol, nicotine, herbal and supplements, alternative therapies, and caffeine may have an impact on a drug’s effect.  Always ask specifically about all types of medications that the patient might use including contraceptives.  History of Allergies  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 information about the 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.  Level of Education and Understanding  It provides a baseline from which the nurse can determine the appropriate types of teaching information to use with the patient.  Stress, disease, and environmental factors can all affect a patient’s learning readiness and ability.  Social and Financial Support  Discharge planning involves determining what support is available to the patient at home.  Financial constraints may cause a patient not to follow a prescribed drug regimen.  Referral to appropriate community resources must be considered.  Pattern of Healthcare  Knowing how a patient seeks health care provides the nurse with valuable information to include when preparing the patient’s teaching plan.  Does this patent 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 health care provider?  B.) Physical Examination  These determine if any conditions exist that would be contraindications or cautions for using the drug and to develop a baseline for evaluating the effectiveness of the drug and the occurrence of any adverse effects.  Weight  It 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, the responsiveness of other organs and other existing medical conditions.  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. Physical Parameters Related to Disease or Drug Effects  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. Physical Parameters Related to Disease or Drug Effects  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.  Patient History/ Information  “Chief complaint” What brought them to the facility  Drug allergy and type of reaction  Past medical history  Medications used  Personal and Social History( Alcohol, tobacco, or caffeine, street or illicit substances, Reproductive questions such as pregnancy (women of childbearing age). Risk factors; meds that can harm fetus  Should also include OTC, Dietary supplements, and herbal products  Culture and Religious beliefs  Immunization status  Implants  Health History Questions Pertinent to Drug Administration Health History Component Areas Pertinent Questions Chief complaint How do you feel? (describe) Are you having any pain? (describe) Are you experiencing other symptoms (Especially pertinent to medications are Nausea, vomiting, headache, itchiness, dizziness, shortness of breath, nervousness, palpitations or “ weakness or fatigue Allergies Are you allergic to any medications? Are allergic to any foods, environmental substances (e.g. pollen or seasonal allergies, tape, soaps or cleansers) What specifically happens when you experience allergy? Past Medical History Do you have history of diabetes, heart or vascular conditions, respiratory conditions or neurologic conditions? Do you have any dermatologic conditions? How were these treated in the past? Currently? Family Medical History Has anyone in your family experienced difficulties with any medications? (describe) Does anyone in your family have significant medical problems? (describe) Drug History What prescription medication are you currently taking?(List drug name, dosage and frequency of administration) What nonprescription/over the counter medications are you taking? (List drug name, dosage and frequency of administration) Health-risk History Do you have any history of depression or other mental illness? Do you use any street drugs or illicit substances? Personal Social History Do you smoke? What is your usual alcohol intake? What is your usual Caffeine intake? Do you have religious or cultural beliefs or practices concerning medications or your health that we should know about? What is your occupation? What hours do you work? ASSESSMENT RELATED TO DRUGS  Is the drug order valid? A drug order must be written by a physician, dentist, physician assistant, or advanced practice nurse and contain: The date and time the order is written The name of the drug The dosage The route of administration The frequency of administration The duration (how long the patient is to receive the drug) The signature of the prescriber  ASSESSMENT RELATED TO DRUGS  Identify the brand and generic name for the drug The chemical name used by pharmacists and researchers. (eg. 1-(isopropylamino)-3-(1-naphtyloxy) propan-2- ol) The generic name, which is the official (proprietary) non-proprietary name that is universally accepted. The brand name, which is the name chosen by the drug manufacturer.  ASSESSMENT RELATED TO DRUGS  When is the drug used? The nurse is required to know why the drug is given to the patient and what symptoms a patient exhibits to indicate that the drug should be administered. Medication errors can be reduced or eliminated if everyone involved in the process uses critical thinking skills and checks and double checks the orders, the patient, and the medication.  ASSESSMENT RELATED TO DRUGS  How does the drug work? It is critical that the nurse understands how the drug is absorbed, distributed, metabolized, and eliminated before administering the drug to the patient. The nurse must also know the drug’s onset of action, peak action, and duration of action.  ASSESSMENT RELATED TO DRUGS  What interacts with the drug? The effectiveness of a drug can be influenced by interactions with food, herbal remedies, and other drugs that alter or modify the drug’s action.  ASSESSMENT RELATED TO DRUGS  What are the side effects and toxicity of the drug? By knowing a drug’s possible side effects, the nurse can prepare to manage them before the patient is given the drug. The nurse must also know the toxicity of a drug.  ASSESSMENT RELATED TO DRUGS  What signs and symptoms must be monitored? The nurse must note the signs and symptoms that indicate the patient is having an adverse reaction to a drug or that the drug has reached toxic levels.  ASSESSMENT RELATED TO DRUGS  What must a patient know about the drug? Many drugs are self-administered by patients after they leave the healthcare facility.  ASSESSMENT RELATED TO DRUGS  Is the drug available? Has the drug expired? How much does the drug cost? The drug that is ordered may not be available in the healthcare facility. The nurse must make sure the drug is available and make sure that the drug on hand hasn’t expired if it is available. The cost of the drug is important to know for a number of reasons. II. NURSING DIAGNOSIS  It is simply a statement 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.  It shows actual or potential alterations in patient function based on the assessment of the clinical situation.  Diagnoses that are related to drug therapy must be incorporated into a total picture of the patient.  For example, a physician might diagnose a patient as having diabetes and prescribes glucose monitoring and insulin injections to control the disease. “knowledge deficit about the disease and the medications to treat it.”  EXAMPLES: Knowledge deficit of disease and medication related to inability to under stand English. Risk for injury related to side effects of drug Alteration in thought processes related to drug action  EXAMPLES: Constipation related to drug action or side effect. Fluid volume deficit related to drug action Breathing pattern ineffective related to drug side effects  III. PLANNING  Review patient allergies.  Review and reconcile prescribed medications.  Identify possible adverse effects of medications.  Identify potential interactions with other medications.  Determine route of administration.  Determine time of administration.  Develop patient education regarding medication administration.  The nurse delineates specific interventions directed at solving or preventing the problems identified in analysis Plan must be individualized for each patient.  When creating a care plan, the nurse must  Define goals  Set priorities  Identify nursing interventions  Establish criteria for evaluating success  Planning is an ongoing process that must be modified as new data are gathered and the patient’s situation changes.  Examples of well written comprehensive goals are: 1.Patient will independently administer prescribed dose of insulin by end of the fourth session of instruction 2. Patient will prepare a medication recording sheet that correctly reflects prescribed medication schedule within 3 days. IV. IMPLEMENTATION  Interventions involve ensuring effective response to drug therapy, minimizing adverse effects, and understanding the drug regimen.  Three types of nursing interventions: drug administration, provision of comfort measures, and patient/family education.  A. Proper Drug Administration 10 Rights: 1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time and Frequency 6. Right History and Assessment 7. Right Documentation 8. Drug approach and Right to Refuse 9. Right Drug-Drug Interaction and Evaluation. 10.Right Education and Information. Right Drug  Medication orders maybe prescribed by: 1.Physicians 2.Dentist 3.Podiatrist (foot doctor) 4.Licensed health care providers *prescription- written on prescription pad *drug orders- written in order sheet included in patients chart. Six elements of Drug Order  Name of the patient  Date order is written (start/stop)  Name of Medication  Dosage of medicine (size, frequency and number of doses)  Route of delivery  Signature of the prescriber Right Dose  Dose prescribed for a particular patient. Drug Dosage Calculations  Drug dosage calculations are required when the amount of medication ordered (or desired) is different from what is available on hand for the nurse to administer.  Formula: Amount DESIRED (D) Amount on HAND (H) X QUANTITY (Q) = Y (Tablets/mL Required) Note: When medication is given in tablets, the QUANTITY = 1 since the amount of medication available is specified per (one) tablet. Example 1: Metoprolol, 50 mg PO, is ordered. Metoprolol is available as 100 mg per tablets. How many tablets would the nurse administer? Step 1: D= 50mg H= 100mg Determine your Q= 1 givens Step 2: Plug in what you know into the formula and simplify. Example 2: 1200 mg of K-lyte is ordered. This medication is only available as 600 mg per tablet. How many tablets should the nurse give? Step 1: D= 1200mg H= 600mg Determine your Q= 1 givens Step 2: Plug in what you know into the formula and simplify. Example 3: Dilantin-125 is available as 125 mg/5 mL. Dilantin-125, 0.3 g PO, is ordered. How much should the nurse administer to the patient? Step 1: Determine your (D) = 0.3 g (H) = 125 mg givens. Q = 5 mL Step 2: Convert 0.3 g to mg (since the ordered dose is in grams but the drug is available on hand in milligrams). Step 3: Plug in what you know into the formula and simplify. Example 4: Furosemide is available as 20 mg in 2mL.10 mg is ordered to be administered through an IV. What amount of furosemide should the nurse administer? Step 1: D= 10mg H= 20mg Determine your Q= 2 givens Step 2: Plug in what you know into the formula and simplify. Practice: Desired dose Stock dose mL? Ranitidine 27mg 25mg/mL in 2mL 1.08ml ampoule Ceftriaxone 700mg 1g/vial, dilution 10mL 7ml Hydrocortisone 60mg 100mg/vial, dilution 1.2ml 2mL Paracetamol 200mg 150mg/mL in 2mL 1.33ml ampoule Metoclopramide 5mg/mL in 2mL 2ml 10mg ampoule Calculation of Intravenous Drip Rates  In these types of calculations, for a given volume, time period, and drop factor (gtts/mL), the required IV flow rate in drops per minute (gtts/min) is calculated. Drop Factor: the number of drops in mL of solution  Macro drip sets have 10, 15, 20 gtts/ml or drops/ml  Micro drip sets have 60gtts/ml or drops/ml  Formula: gtts/min Volume (mL) Time (min) x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) Note: Since a fraction of a drop is not possible to give to a patient, it is usual to round the answers to the nearest whole number. Example 1: Calculate the IV flow rate for 1000 mL of PNSS to be administered over 8hrs. The infusion set has drop factor of 15 gtts/mL. Step 1: Determine Volume: 1000 mL Time: 8 hours your givens. Drop factor: 15 gtts/mL Step 2: Convert 8 hours into minutes. Step 3: Use the formula to calculate the IV flow rate (gtts/min).  Formula: mL/hr Volume (mL) Time (H) = Y (Flow Rate in mL/Hr) Note: The flow rate depends on the volume of fluid ordered and the time of infusion. Example 2: 1000 mL D5W IV is ordered to infuse in 10 hours. Calculate the flow rate in milliliters per hour. Step 1: Determine your Volume: 1000 mL Time: 10 h givens. Step 2: Since the volume is given in mL and the time is given in hours, the flow rate can be calculated in one step using the formula. Step 3: Use the formula to calculate the IV flow rate (mL/hr). Example 3: 600 mL of antibiotic is to be infused over the 180 minutes by an infusion pump. Calculate the flow rate (mL per hour). Step 1: Determine your Volume: 600mL Time: 180 min givens. Step 2: Convert 180 min into hours since the flow rate must be stated in mL/h. Step 3: Use the formula to calculate the IV flow rate (mL/hr).  Right Time  Time at which the prescribed dose should be administered 1. Administer at specific time. 2. Administer that are affected by foods before meals. 3. Administer that can irritate the stomach without foods. 4. Drug administration schedule maybe adjusted to fit the clients lifestyle, activities, tolerance or preference. 5. Check for expiration date. Right Route  Necessary for adequate absorption 1. Assess ability to swallow before administration 2. Do not crush/ mix medication in other substances without consulting the pharmacist (Don’t mix with sweet substances/Don’t mix in an infant’s formula feeding) 3. Use aseptic technique when preparing and administering drugs (parenteral route). 4. Administer at the appropriate site. 5. Stay with client until oral drugs have been swallowed. Right Patient Nurse must verify the client’s identity before any drug administration.  Verify by checking the identification bracelet  Some institution have ID bracelets coded for allergy status. Right Documentation Requires the nurse immediately record the appropriate information about the drug administered.  Name of drug  Dose and route of administration  Time and date of administration  Nurse’s initials/signature  Response to medication Right Assessment Requires appropriate data must be collected before administration of the drug Right to Education Requires that client receive accurate and thorough information about the medication and how it relates to his/her health status. Right to Education Patient teaching should include:  Therapeutic purpose  Possible SE  Any diet/lifestyle restrictions  Skill of administration  Lab monitoring Right to Education Coincides with the principle of informed consent.  Based on the individual having the knowledge necessary to make a decision. Right Evaluation  Requires effectiveness of the medication be determined by the client’s response to the medication.  Appropriate to determine the extent of side effect and adverse effects, if any. Right to Refuse  Patient can and do refuse to take a medication. Nursing action when client refuses to take medication  When refused, refusal should be documented immediately.  Explain the risk of refusing to take the medication and reinforce the reason for medication.  Inform the nurse manager or health care provider when an omission and refusal to take medication pose a specific threat to the patient.  Types of Medication Orders  Standing Medication Orders  First, we will look at standing medication orders. A standing medication order is a set of prewritten orders that a nurse can use to administer treatments and medications.  These are usually written by a specific practitioner and allows the nurses to administer certain medication without a physician order. In a way, these are the physician orders. Standing orders are approved by the practitioner.  Standing orders are used until they are canceled or until the number of days has passed for the standing order. These orders usually contain the number of treatments to be given and how long the treatments should last.  PRN Medication Orders  Secondly, there are PRN medication orders. These medications are only given when the patient requires them. Medications for pain relief, sleep, and nausea can be written as PRN orders. Sometimes you will find medications for blood sugar and high blood pressure given as a PRN medication order.  PRN medication orders usually have instructions and guidelines for when, what dose, and how often the medication should be administered. PRN medication you must use assessment and discretion when administering.  Single One-Time Medication Orders  Thirdly, there are single one-time medication orders. These medications are given only once at a specific time. Medications given preoperatively are usually single one-time medication orders.  Medications used to treat an acute symptom may be given as a single one-time order. And medications used for diagnostic procedures are given as a single one-time dose.  Once the dose is given the order is no longer active. If the patient needs another dose of the same medication another order must be written.  Stat Medication Orders Fourthly, there are stat medication orders. These orders are for a medication that must be given immediately. These orders are also for a single dose of medication. A stat order may be written and another order to continue the same medication for a specific time at a specific dose. This medication order must include all the requirements of any medication order. Stat orders are usually written in emergent situations.  Now Medication Orders Finally, there are now medication orders. These orders are written when the patient needs the medication quickly but not immediately. The now medication order is also a single one-time dose of medication. There is usually an hour window of time to give a now order medication, but as always check your facility’s policy.  B. Comfort Measures  A patient is more likely to be compliant with a drug regimen if the effects of the therapy are not too uncomfortable or overwhelming.  PLACEBO EFFECT The anticipation that a drug will be helpful has proved to have tremendous impact on the actual success of drug therapy. 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. 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) LIFESTYLE ADJUSTMENT  Some medications and their effects require that a patient make changes in his or her lifestyle.  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.  C. Patient and Family Education It is essential that they have allow the information necessary to ensure safe and effective drug therapy at home. In fact patients are now given written information. Medication Abbreviation Frequencies for Administration Times and Orders a before p after ac before meals pc after meals q every OD Once a day Hr, hr, h hour min minute BID Twice a day TID Three times a day QID Four times a day STAT immediately PRN As needed adlib As much as patient’s desire HS At bedtime/ hour of sleep  3 Types of Intervention  Nurse-initiated intervention  Physician or advanced practice intervention  Collaborative intervention V. EVALUATION  Each outcome on the care plan must be evaluated to determine if the goal is achieved. Once all goals on the care plan are reached, the care plan no longer exists.  The patient no longer exhibits symptoms of the nursing diagnosis. THANK YOU!!!