The Nursing Process in Drug Therapy
and Patient Safety
Upon completion of this lesson, you will be able to:
1.
List 5 phases of nursing process
2.
Utilize nursing process as a framework in ensuring patient safety
in drug administration
3.
Compare and contrast the 10 Rights of Medication
Administration
The nursing process is a well-established, research-supported
framework for professional nursing practice. It is a flexible,
adaptable, and adjustable five-step process consisting of
assessment, nursing diagnoses, planning (including establishment of goals and
outcome
criteria), implementation (including patient education), and evaluation.
1. Assessment - Information gathering
• Involves systematic validation, organized collection of data about the
patient’s physical, intellectual, emotional, social and environmental
information.
• It includes anthropometric measurement, physical assessment, and
past health history of the patient.
Subjective Data
Objective Data
Current health history
Physical Assessment
Patient symptoms
Diagnostic results
Current medications
Past health history
Patient’s enviroment
2. Diagnosis - It is the statement of the patient’s status from a nursing perspective
through thorough analysis of gathered information to arrive at a conclusion, goal
or a plan. These diagnoses are derived from North American Nursing
Diagnosis Association (NANDA). Check you NANDA book!
3. Planning - This is characterized by goal – setting or expected outcomes.
Goals are patient centered, describe the specific activity, and include a time
for achievement/reevaluation. What do we really want to achieve to our
patients?
4. Intervention and Rationale - Involves taking the information gathered and
synthesized into nursing diagnoses to plan the patient care. It involves
Proper drug administration, provision of comfort measures, health teachings
and lifestyle adjustments
5. Evaluation -Is part of the continuing process of patient care that leads to
changes in assessment, diagnosis and implementation. The patient must
be continually evaluated for therapeutic response, occurrence of adverse
drug effects, and drug interaction.
You see it is a process of problem-solving that has a goal. It is a continuous
process because it does not stop when you finish evaluating. You need to start all
over again. The nursing process even extends when the patient leaves the hospital
and stays at their house. It is what we should always live by.
“FIVE-PLUS-FIVE” RIGHTS OF MEDICATION ADMINISTRATION
In all of these five phases of nursing practice, safety is a consideration. Below is a
discussion on how we can ensure safety of our patients whenever we administer
drugs.
1. Right Patient – as a nurse you should always identify your patients correctly.
Baka kasi mabigyan mo ng pagaaruga ang maling tao! What should you do?
a. Verify the patient by checking the patient’s identification bracelet
b. Highlight patient’s name with bright colors
c. Ask the patient’s name
2. Right Drug - Drug orders and label should be read 3 times
3. Right Dose – Refers to the verifications by the nurse that the dose
administered is the amount ordered and that is safe for the patient for whom it
is prescribed. Is this the correct amount of the drug?
REMEMBER: When in doubt, recalculate!!!
a. single order is for a drug that is to be given only once, and at a specific
time
b. A prn order is administered as required by the patient’s condition (PRN
= whenever necessary).
c. Routine orders are usually carried out within 2 hours of the time the
order is written by the health care provider.
d. Standing order is written in advance of a situation that is to be carried
out under specific circumstances.
4. Right Time- It is the time the prescribed dose is ordered to be administered.
Note: Use of military time reduces administration errors and decreases
documentation; and check for the expiration date of the drug.
Common Abbreviations used to indicate time:
Abbreviation
Meaning
Definition
AC
ante cebum
Before meals
PC
post-cebum
After Meals
prn
Pro re nata
Whenever necessary
Hs
Hora somni
hours of sleep
OD
Once a day
BID
Bis in die
Twice in a day
TID
Ter in die
Thrice in a day
QID
Quarter in die
4 times a day
q
Every
h
hours
5. Right Route - This is to ensure that the drug is appropriately absorbed by the
body. This is ordered by the physician.
Common Abbreviations used to indicate right route:
Abbreviation
Meaning
PO (Per orem)
Taken orally
NPO
Nothing per orem
SL
Sublingual; placed below the tongue
Topical
Instillation
Applied on the skin usually comes in
gel/lotion
It is instilled like an eye or ear drop
inhalation
Inhaled, like nebulization
IV
Intravenous
IM
Subq
Intamuscular; administered in your
muscle.
Subcutaneous
ID
Intradermal
Remember, whenever you give medications, you need to remember few
things:
1. Assess patient’s ability to swallow (kailangan to, baka he cant swallow,
maltutan!)
2. Make sure PT is not on NPO
3. Do not crush or mix medications without consulting reliable sources.
4. Do not mix with infant formula
5. Use antiseptic techniques in administering drugs
6. Stay with patient until oral drugs have been swallowed.
Here is an example of a complete and correct medication order:
Give Paracetamol 300 mg IV q8h PRN for Temp >37.9oC
We can interpret it in this manner:
Drug: Paracetamol (What drug we will give?)
Dose: 300 mg (how many?)
Route: IV (intravenous) (where do we
administer it?) Time: Every 8 hours (how
often should we give it?
Consideration: for temperature greater than 37.9 oC. (give it ONLY if it
exceeds given temperature parameter)
6. Right Assessment:
It requires collection of appropriate data before
administration of drugs. You need to remember that drugs produces physiological
changes.
Take this example: Digoxin is a cardiac glycoside with positive inotropic
characteristics. It means that it can effectively lower the heart rate. So
before giving the drug make sure that you have assessed the heart rate of
your patient. If not, it may drastically lower an already abnormally low heart
rate. (patay ang patient).
7. Right Documentation - Requires the nurse to immediately record the
appropriate information about the drug administered.
Remember to identify the following: Name of drug, dose, route, time,
date and nurse’s signature, Patient’s response to the medication,
how the order was given, telephone order (given via call or sms) or
verbally (dictated).
8. Right Education - Requires the patients to receive accurate and thorough
information bout the medication and how it relates to their particular condition. It
includes therapeutic purpose, expected result, dietary restrictions, skills in
administration,
NOTE: The right is a principle of Informed Consent
9. Right Evaluation - It refers to an appraisal of the drug’s therapeutic and adverse
effects. “Did the medication do for the patient what it was supposed to do?”
Question: Sir is this the same thing with right assessment because it
involves appraising?
If you have the same question like this in mind, I applaud you. But the
answer is NO. Yes, it involves collection of information the same with the
right assessment but take note of the TIME. Right assessment id performed
BEFORE giving the drug, while right evaluation is performed AFTER you
have given the drug. It is a matter of time.
10. Right to Refuse - The patient has the right to refuse in taking the medication.
However, it is the nurse’ responsibility to determine the cause of the refusal.
Furthermore, the refusal must be documented.
You always need to understand that giving drugs entails legal liabilities
because the lives of your patients. Nursing is not only taking Blood pressure,
it is far from just that!
Interestingly, nurses have also rights in giving medications. These rights, like the
rights of the patient, provide additional layer of safety by ensuring that the nurse
has what is needed to provide safe medication administration. After 4 years,
remember your following rights:
1. Right to a complete and clear order - To question the health care provider if the
order is not complete or is unclear
2. Right to have the correct drug, route (form), and drug dispensed.
3. Right to have access to information – This includes the right to expect current
and readily accessible drug information (e.g., hospital formulary, nursing drug
reference). This right is a must. Nurses are only to administer drugs with which
they are knowledgeable
4. Right to have policies to guide on safe medication administration - Health
care administration’s role is to provide the structure on which nurses administer
drugs safely. In each facility, policies guide nursing practice.
5. Right to administer medication safely and identify problems in the system encompasses nurses’ right and responsibility to speak up when they are first aware
of situations that impinge negatively on safe administration of medications. Nurses
should be an advocate for safety in the health care setting
6. Right to stop, think, and be vigilant when administering medications - When
unsure, nurses have the right and responsibility to stop and think, consult with other
health professionals, and check their institution’s policies.
Safety is the basis for these actions. Do not get pressured. But make sure time is
not your enemy in this situation.
But what happens when we commit and error in giving medication? What should you
do? We can justify this by saying “tao alng ako, nagkakamali din”. Why do we commit
an error?
The Food and Drug Administration (FDA) and the American Hospital Association
track common causes of drug errors that occur in health care settings are the
following:
 Incomplete patient information (e.g., incomplete or missing patient information
such as allergies or current medications in use; lack of previous diagnoses or
lab results)
 Unavailable drug information (e.g., black box or other warnings issued by the
FDA)
 Miscommunication of drug orders (e.g., inappropriate abbreviations, use of
metric and other dosing units, similar drug names)
 Lack of appropriate labeling when a drug is prepared and repackaged into
smaller units
 Distracting environmental factors (e.g no room to prepare drugs, noisy
environment, number of patients)
Medication Reconciliation - Is the process of comparing a patient’s medication orders
to all of the medications that the patient has been taking to prevent errors (omissions,
duplications, dosing errors, drug interactions)