The Nursing Process and Drug Therapy

The Nursing Process and Drug Therapy

I Information Gathering
A. Assessment
1. objective information: things that can be viewed by others.
a. Ex: lab reports, scar on arm
2. subjective information: the pts opinion
B. Medication Information
1. allergies: drug, foods, herbal, environmental
a. VERY IMPORTANT to know what happened during the reaction
b. a rash or anaphylaxis and/or rash are allergic reactions, tummy upset is intolerance.
2. prescription medications
3. OTC meds
4. herbals, supplements, vitamins
5. illicit drugs
6. Ask if any medications are recent (within the last 2 months) and if any reactions
7. Ask if any meds prescribed by doc, but not taken. Especially if admitted to the hospital. Ex: Water pills prescribed but not taken and the pt now has CHF.

II Continuum of Care
A. JCAHO Initiative: Joint Commission on Accreditation of Healthcare Organizations.
1. Integrates outcomes and performance measures into accreditation process.
2. Has written policy and procedures to prevent errors. (set of standards on a list)
3. Hold hospitals to standards so they can get medicaid/medicare funding.
B. Hospitals and all JCAHO accredited bodies must show that when a pt is admitted, transferred, or returning from surgery, that all medications are reconciled.
C. National Patient Safety Goals
D. rules:
1. READ THE LABEL
2. READ THE VIAL
3. READ THE TABLET
4. IF MORE THAN TWO OF ANYTHING, DOUBLE CHECK

III Parts of an MD Order (Components of a full/complete order)
A. Pt’s name and ID
B. Date and time order was written. (JCAHO mandate)
1. Usually in military time, but definitely distinguish from am and pm.
C. Name of medication
D. Dosage
E. route
F. frequency
G. monitoring parameters
H. signature
I. legibility
1. must have a leading zero before the decimal.
2. do not use trailing zeros
J. DNU abbreviations (DO NOT USE) See the do not use list: qd, qid, etc.

IV Five Rights
A. Right Drug
1. know what the drug is used for
2. compare drug package to label
3. compare label to MAR (medication administration record) or medication order
B. Right Dose
1. verify as in Right Drug
2. must be sure the amount is correct. Account for size and age.
3. EXTRA caution in neonates, pediatrics, critically ill, elderly
4. If multiple tablets or vials are ordered, call the pharmacy to be sure of correct dosage. “More than 2 of anything...call the pharmacist.”
C. Right Time
1. Know the institute’s policy where you work.
2. know your “buffers”.
a. Can a dose be given 1 hour early or late?
b. What are the consequences?
c. Does it matter?
d. It is important to know what to do if dose is late.
D. Right Route
1. VERY IMPORTANT to know how the drug is given.
a. Physician’s orders dictate care.
2. Oral, IV, IM, Intradermal, Enteral, continuous infusion, piggy-back, push.
3. Rule: If you have to go through a lot of work to get it into a patient, take a time-out and call pharmacy.
4. IV medications are rarely cloudy or thick.
a. Some meds are very thick, but if it looks like a syrup...it probably is. (oral = syrup)
E. Right Patient
1. MOST IMPORTANT RIGHT the easiest meds are the most often given incorrectly
2. ALWAYS, always verify the patient via the institutions correct policy and procedure. Even if you have worked with the pt for days.
3. Normally utilize the pt name, and one of the following:
a. medical record number
b. financial number
c. SSN
d. DOB
4. Never use the pt’s room number or ID by physical appearance.

V Evaluation
A. Occurs after the plan has been implemented
1. Has the medication worked?
2. Is pain resolved?
3. Is BP resolved?
VI Critical Thinking
A. A pt states, “I have never taken these drugs before.” Double check the doctors order!
Ex: a surgery pt given a round of psychiatric drugs