http://evolve.elsevier.com/McCuistion/pharmacology
In their everyday practice, nurses have many important tasks; however, drug administration is at the top of the list. It is estimated that about 40% of the nurse’s time is spent on drug administration, and knowledge of these drugs is essential to patient safety. If unsure about a patient’s medication, consult the health care provider for clarification.
Nurses are often the first line of defense against drug errors in patient care. Federal, state, and local authorities issue regulations and guidelines for practice, and each state has a nurse practice act that defines the scope and function under which the nurse practices. Health care institutions also have policies that help nurses follow federal and state guidelines and regulations.
This chapter focuses on the nursing process as it relates to pharmacology and the safe administration of patient drugs with a focus on patient- and family-centered care. Chapter 9 offers additional information on safety in pharmacotherapy.
The Quality and Safety Education for Nurses (QSEN) initiatives guide nurses in the practice of safe, comprehensive care. QSEN offers competencies to provide structure and encourages professional development while advocating for safe patient care. QSEN equips nurses with competencies to improve the quality and safety of the health care system in which they work.
The QSEN competencies are as follows:1. Patient- and family-centered care: Recognize the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs.
2. Collaboration and teamwork: Function effectively in nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
3. Evidence-based practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
4. Quality improvement: Continuously improve the quality and safety of health care systems by using data to monitor outcomes of care processes and improvement methods to design and test changes.
5. Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
6. Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
QSEN competencies are integrated throughout the book and are highlighted in special features such as “Patient Safety” boxes and high-alert drug icons.The Nursing Alliance for Quality Care (NAQC) is an organization that supports quality patient-centered health care. The NAQC in partnership with the American Nurses Association (ANA) has published guidelines that support the core principles of patient-centered quality care. These guidelines aim to foster “the patient relationship as the cornerstone of patient safety and quality.” The NAQC’s mission is to advance the highest quality, safety, and value of consumer-centered health care for all individual patients, their families, and their communities. NAQC believes it is the nurse’s role to cultivate successful patient and family engagement, and that fostering family engagement is an essential component in reducing drug errors. The nurse serves as a patient advocate by supporting the patient’s right to practice informed decision making and by maintaining patient-centered engagement in the health care setting. These guidelines include nurses at all levels of education and across all health care settings. Both QSEN and NAQC principles are fundamental to patient-centered practice and safety in pharmacotherapy.
Nursing Process: Patient-Centered Collaborative Care
The nursing process is a five-step decision-making approach that includes (1) assessment, (2) diagnosis, (3) planning, (4) implementation, and (5) evaluation. The purpose of the nursing process is to identify, diagnose, and treat human responses to health and illness. The nursing process is the essential core of practice for nurses. It supports the nurse in prioritizing the safe, timely delivery of drug administration. The nursing process is continuous and moves back and forth between the various steps. Careful attention to each phase of the process promotes the patient’s success with the prescribed medication regimen. These steps are discussed as each relates to health teaching and drug therapy.
Assessment
During the assessment phase, the nurse is gathering information from the patient about the patient’s health and lifestyle. Assessment includes both subjective and objective data. Always perform a complete, systemic assessment of the patient’s body systems. In this assessment, the nurse asks the patient questions about the illness and about the drug regimen. The nurse can also get information from family members, health professionals, and the medical record. The assessment phase is paramount because the nurse will use the information gathered to form the basis of the patient’s plan of care, which includes drug administration. Careful attention to each phase of the nursing process encourages the patient’s success with the prescribed medication regimen.
Subjective Data
Subjective data include information provided verbally by the patient, family members, friends, or other sources. The patient must verbalize subjective data, which are imperceptible by the nurse’s senses. The nurse may ask open-ended questions that allow the patient to answer directly, such as “Please tell me about your current medications.” The nurse may help the patient explain or describe subjective data but must never speak for the patient. Subjective data comprise what the patient personally has to say about his or her medications, health problems, and lifestyle. Examples of pertinent information that the nurse can use to help solicit subjective data from the patient concerning medication administration include the following:
• Current health history, including family history
• Swallowing problems (dysphagia)
• Signs and symptoms of the patient’s illness verbalized by the patient
• Current concerns about the patient’s:
• Knowledge about medications and side effects
• Over-the-counter (OTC) remedies, nutritional supplements, herbal remedies, and contraceptives
• Knowledge of side effects to report to the physician
• Attitude and beliefs about taking medications
• Allergies
• Financial barriers
• Use of tobacco, alcohol, and caffeine
• Cultural dietary barriers
• The patient’s home safety needs
• Caregiver needs and support system
Enhancing the patient’s adherence to the drug therapy regimen is an essential component of health teaching. The patient’s attitudes and values about taking medication are important considerations when determining readiness to learn. Attitudes and values should be considered when planning interventions to support the patient’s decision to adopt healthy behaviors related to medications. In addition, the patient’s social support system should be emphasized. This special support system is unique to the individual and may be composed of persons who assist in preparing drugs, organizing pills, and ordering medications. A support system can alert a patient to side effects, encourage actions that promote medication compliance, and notify the health care provider if a problem arises.
Objective Data
Objective data are what the nurse directly observes about the patient’s health status. It involves collecting the patient’s health information by using the senses: seeing, hearing, smelling, and touching. Objective data collection provides additional information about the patient’s symptoms and also targets the organs most likely to be affected by drug therapy. For example, if a drug is nephrotoxic, the patient’s creatinine clearance should be assessed.
The following are examples of objective data concerning medication administration:
• Physical health assessment
• Laboratory and diagnostic test results
• Data from the physician’s notes (i.e., health history)
• Measurement of vital signs
• The patient’s body language
Nursing Diagnosis
A nursing diagnosis is made based on analysis of the assessment data, and it determines the type of care the patient will receive. When data show an abnormality during the assessment, it can serve as the defining characteristic of a problem to support the appropriate nursing diagnosis; and more than one applicable nursing diagnosis may be generated. The nurse formulates nursing diagnoses and uses them to guide the development of a care plan to provide patient-centered quality care.
Common nursing diagnoses related to drug therapy include the following:
• Pain, Acute or Chronic, related to surgery
• Confusion, Acute related to an adverse reaction to medication
• Health Maintenance, Ineffective related to not receiving recommended preventive care
• Knowledge, Deficient related to effects of anticoagulant medication
• Noncompliance related to forgetfulness
• Health Management, Ineffective related to lack of finances
Use of nursing diagnoses is beneficial to patient care because it facilitates the development of an individualized care plan for each patient. It is important to note that a nursing diagnosis is different from a medical diagnosis, which identifies a disease condition and the results of diagnostic tests and procedures.
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