How to develop better care plans by
applying nursing diagnoses to problems with
your patients' drug therapy.
BY MEREDITH A N N McCORD, RN. MS
Assistant Professor • Oregon Health Sciences University • School of Nursing •ftjrtland.Oregon
ursing diagnoses help you
identify patient problems and
establish priorities of care.
Among the most common di-
agnostic labels used by nurses
to develop care plans for the
management of a patient's drug regi-
men are "knowledge deficit" and
"noncompliancc." You may also iden-
tify other nursing diagnoses, depending
upon the potential risks or adverse ef-
fects occurring secondary to drug ther-
apy. Consider how you might use these
diagnoses with your patients.
Knowledge deficit
A knowledge deficit can occur for var-
ious reasons, depending on the etiol-
ogies and defining characteristics you
identify. For example, defining char-
acteristics for a knowledge deficit
might include:
• statement of misconception
• verbalization of the problem
• request for information
Adapted from the if w pharmacutoKy textbook Clinical
Pharmacology and Nursing bvCiaroUL.Saer, RN, PhD,
and Bradley R. Williams, PharmD. D I9SS Springhouse
Corp.. Springhouse. Pa.
80 Nursing88, October
• inaccurate follow-through of in-
struction
• inadequate test performance
• inappropriate or exaggerated behav-
iors.
Your diagnosis depends upon the as-
sesstnent data on and drug regimen for
each patient. The following case illus-
trates how a knowledge deficit can re-
sult from several causes.
Mrs. Kaminsky. age 71. entered the
hospital with shortness of breath and
difficulty walking because of edema
and pain in her legs. She was diagnosed
as having congestive heart failure and
was started on the following medica-
tions: digoxin 0.25 mg P.O. daily, fu-
rosemide (frusemide, Lasix) 40 mg
P.O. daily, and potassium chloride
(K-Tab) 2 tablets P.O. twice a day. Mrs.
Kaminsky*s only significant medical
history is a 2-year history of hyper-
tension, which is being monitored by
her family internist. Mrs. Kaminsky
takes no other drugs except for a cal-
cium supplement and daily vitamins.
At this time, she can perform her
routine daily activities without short-
ness of breath. Her legs remain slightly
swollen, though greatly decreased in
size from the time of admission, and
her weight remains 3 pounds above her
expected dry weight. She is to be dis-
charged in about 3 days if no compli-
cations arise.
Mrs, Kaminsky lives alone, although
her son and his family live nearby. She
wants to return to her home and asks
questions regarding her drugs, diet,
disease, and activity levels.
In Mrs. Kaminsky's case, you may
be dealing with a "knowledge deficit,
related to the new drug regimen." a
"knowledge deficit, related to the pre-
scribed diet." or a "knowledge deficit,
related to the self-management of con-
gestive heart failure" diagnosis,
Noncompliance
Noncompliance is another diagnostic
label that can occur when you deal with
a patient and a specified drug regimen.
Some defining characteristics of non-
compliance include:
• behavior indicating failure to follow
a regimen, supported by direct obser-
vation or statement by the patient or
significant other
• failure on objective tests
• evidence of the development of com-
plications
• exacerbations of the symptoms
• failure to keep appointments
• failure to progress
• inability to set or maintain mutual
goals.
The following example illustrates
some of the identifying characteristics
of noncompliance; Mr. Miller, age 65.
is admitted to the hospital with an ex-
acerbation of his emphysema. Within
the past 12 months. Mr. Miller has en-
tered the hospital three times with the
same medical diagnosis. Each time, he
received intravenous antibiotics, ste-
roids, and oxygen.
During Mr, Miller's present admis-
sion, you note the following charac-
teristics as part of the assessment, "The
patient is alert, exhibits circumoral cy-
anosis, has a respiratory rate of 32 with
the use of accessory muscles, has
breath sounds with scattered insptra-
tory and expiratory wheezes through-
out and crackles in the posterior bases,
has a cough productive of thick yellow-
green secretions, and states his short-
ness of breath has increased over the
past 2 weeks, until he now needs as-
sistance to perform his daily activities.
The patient has a 50 pack-year history
of smoking; he smokes one pack per
day and has refused to decrease this.
He states that he quit taking his drugs
2 weeks before admission because they
did not seem to make any difference in
how he felt and were expensive. Upon
further discussion. Mr. Miller could
not state the effects of his drugs and
treatments,"
Mr. Miller lives with his wife, who
also has several medical problems that
require treatment. He is on a fixed in-
come; he has insurance, the benefits of
which are almost exhausted; Medicare:
and Social Security, During the present
admission, the patient's respiratory sta-
tus has improved. He performs his reg-
ular activities with minimal shortness
of breath, although he needs oxygen at
night. Upon discharge, he is to take
prednisone 40 mg RO,. which should
be tapered over the next 2 weeks ac-
cording to a set schedule, theophylline
(Theo-Dur). metaproterenol {Alupent
Inhaler), beclomethasone (Vancenase
Nursing88, October 81
 Inhaler), Lasix. potassium chloride
(K-Lor), and cephalexin (Keflex) for
10 days, and use oxygen at night.
The defining characteristics for Mr.
Miller include his repeated admissions
for the exacerbation of emphysema;
discontinuance of treatment; question-
able understanding of the prescribed
treatment; minimal resources to pay for
treatment; and your assessment find-
ings, including shortness of breath,
wheezes and crackles, the use of ac-
cessory muscles for breathing, and an
increased respiratory rate. You need to
collect more information about Mr.
Miller's disease knowledge and his be-
liefs about the effects of the treatment.
You may be dealing with "noncompli-
ance, related to a misunderstanding of
the importance of the prescribed drug
regimen" or "noncompliance, related
to a lack of financial resources."
Other diagnostic iabels
For alteration in health maintenance,
another commonly used diagnostic la-
bel, the identified defining character-
istics include:
• a demonstrated lack of knowledge
about basic health practices
• a demonstrated lack of adaptive be-
haviors to internal or external environ-
mental changes
• a reported or observed inability to
take responsibility for meeting basic
health practices in any or all functional
pattern areas
• a history of lacking health-seeking
behavior
• an expressed interest in improving
health behaviors
• a reported or observed lack of equip-
ment or financial resources or other re-
sources
• a reported or observed impairment
of personal support systems.
Possible nursing diagnoses related to
"alteration in health maintenance" may
resemble the following: "alteration in
health maintenance, related to the pa-^
tient's inability to comprehend the es-
tablished drug regimen," "alteration in
health maintenance, related to paral-
ysis of the patient's right side," and
"alteration in health maintenance, re-
lated to a cognitive inability to manage
the prescribed drug regimen."
You may formulate and use many
other nursing diagnoses, depending upon
the potential or actual adverse effects of
drug regimens. The North American
Nursing Diagnosis Association has ap-
proved 98 diagnostic labels, from which
these have been developed;
• potential for injury, related to anti-
coagulant therapy
• alteration in skin integrity, related to
a reaction to the prescribed medication
• alteration in oral mucous mem-
branes, related to a superimposed in-
fection (which could be from steroids,
chemotherapy, or antibiotic use)
• alteration in nutrition; less than body
requirements, related to nausea, an-
orexia, and chemotherapy
• sexual dysfunction, related to pre-
scribed medications (such as propran-
olol llnderall).
With such nursing diagnoses, the de-
fining characteristics will depend upon
the patient's specific reaction to the
particular drug regimen. For example,
with the diagnosis "potential for in-
jury, related to anticoagulant therapy,"
the defining characteristics may in-
clude the presence of petechiae, in-
creased bruising, an elevated pro-
thrombin time above therapeutic lev-
els, or the use of aspirin. For the di-
agnosis concerning "alteration in
nutrition," the defining characteristics
may include decreased weight, eating
less than 50% of meals, weakness, or

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 a change in the way foods taste.
Once the nursing diagnosis is for-
mulated, you can proceed to the plan-
ning step of the nursing process,
determining the nursing plan of care
for the patient. This consists of two
major components: the outcome cri-
teria (or patient goals) and nursing in-
terventions.
Developing outcome criteria
The outcome criteria, the first critical
component of the nursing plan of care,
represent patient goals and include the
desired patient behaviors or responses
that should result from the nursing care.
Outcome criteria should exhibit cer-
tain characteristics. First, each out-
come criterion should be expressed as
a measurable and objective statement
that can be answered with yes or no.
For example. '"The patient verbalizes
the major adverse effects related to his
chemotherapy drugs before discharge"
or "The patient demonstrates the
proper administration of her antibiotic
regimen before discharge."'
Next, outcome criteria should be
realistic for each patient. You can't
realistically or appropriately expect
a patient with a chronic respiratory dis-
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Use only one behavior for each out-
come criterion, thereby reducing the
chance of ambiguity and clarifying the
patient goal for other nurses as well as
for the patient. For example, the out-
come criterion "The patient lists and lou might use all the
demonstrates the steps necessary to use correct components when
the Alupent Inhaler" contains two be-
haviors. The patient may be able to list forming an outcome
but not demonstrate the necessary steps criterion yet fail to write a
for using the inhaler, thus producing meaningful statement.
ambiguity about whether the patient
has met the goal. The statement should
be written as two criteria: "The patient
lists the steps necessary for using the
Alupent Inhaler" and "The patient
demonstrates the steps necessary for
using the Alupent Inhaler."
You can further clarify by being as
concise as possible. When developing
a care plan, express the outcome cri-
teria in terms of patient expectations.
For example, "Cephalothin (Keflin) 2
grams will be given q 6 hours" or "The
patient will be turned q 2 hours" rep-
resent nursing interventions, not pa-
tient goals or outcome criteria.
Remember, an outcome criterion states
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 what you want the patient to achieve
after the nursing care. In the first in-
tervention about the Keflin adminis-
tration, a possible outcome criterion
may be; "Patient will be free of infec-
tioti in left leg ulcer" or "Patient ver-
balizes the proper sequence for Keflin
administration." In the intervention
about turning the patient, a possible
outcome criterion may be written as
"patient is free of any redness over
bony prominences."
Finally, each outcome criterion
should be attainable by nursing man-
agement, within a designated time
frame, sueh as "by the time of dis-
charge" or "after the initial teaching
session."
When writing outcome criteria, you
must consider four major components:
the content area, an action verb, a time
frame, and criterion modifiers. For an
explanation of the components, along
with examples, see Writing Outcome
Criteria.
A word of caution: You may use all
of the correct components when form-
ing an outcome criterion yet fail to
write a meaningful statement. For ex-
ample, "The patient will develop crit-
ical thinking in relation to the emer-
WRITING OUTCOME
CRITERIA
The essential components of out-
come criteria and examples of those
components are:
CONTENT AREA
Describes the subject that the pa-
tient will focus on or the response to
be eiicitedt such as
• action of digoxin
• pulse taking
ACTION VERB
Describes how the patient will
achieve the content area aim, such as
• verbalize the action of digoxin
• demonstrate pulse taking
TIME FRAME
Gives a target date for completion of
the outcome criteria, such as
• verbalize the action of digoxin after
the initial teaching session
• demonstrate pulse taking by dis-
charge
CRITERION MODIFIERS
Add specificity to the subject, ac-
tion, or time, such as
• verbalize correctly the major action of
digoxin after the initial teaching session
• demonstrate pulse taking before dis-
charge with a degree of accuracy
within four beats of the pulse the nurse
takes
gency procedures to follow when ad-
verse effects of the chemotherapy oc-
cur at home.'" The statement looks and
sounds impressive, yet no nurse could
accurately measure "develop critical
thinking." Remember, each outcome
criterion should represent a concise
statement that calls for one objective,
measurable patient behavior or re-
sponse.
Nursing interventions
After developing the outcome criteria,
you determine the interventions needed
to help the patient reach the desired
behavior or response goals. Interven-
tions are the actions that you and other
nurses implement to meet the identified
outcome criteria. The types of inter-
ventions and strategies depend upon the
identified nursing diagnosis and out-
come criteria. If the nursing diagnosis
states "knowledge deficit, related to
newly prescribed Lasix."" you may fo-
cus interventions on patient education
for the actions, adverse effects, and
scheduling of Lasix as well as the mon-
itoring of daily weights. If the diag-
nosis states "knowledge deficit, related
to the administration of daily insulin.""
you might develop interventions that

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84 Nursing88, October Circle RSVP #19, or call lolMrM. S M paga 152.
 focus on education for ihe action and
adverse effects of insuiin. steps to take
in case of an insulin reaction, dem-
onstration of self-injection techniques.
' America's first name and observation and guidance for the
in namepms and nurse accessories. patient when administering self-
injections.
Reeves Namepins. The choice of professionals! Remember, the type of strategies or
interventions depend upon the estab-
lished nursing diagnosis, outcome cri-
teria, and the individual patient. (See
7110 Nursing Care Plans for examples
that illustrate the progression from di-
agnosis to outcome criteria to inter-
vention.) By carefully developing a
nursing care plan based on these com-
ponents, you can work toward suc-
cessful management of your patient's
drug therapy and completion of the
nursing process.

WENDY
TWO NURSING CARE PLANS
These two examples show how you might develop nursing care plans for
managing patient problems related to drug therapy.

NURSING DIAGNOSIS
Kriowledge deficit, related to the new drug regimen (includes digoxin, furose-
mide [frusemide, Lasix], and potassium chloride [K-Tab])

OUTCOME CRITERIA NURSING INTERVENTIONS

Before discharge, • Instruct Mrs Kaminsky in the major actions of
Mrs. Kamjnsky will: and possible adverse reactions to each drug.
• Stale the ma|or ac- • Instruct Mrs. Kaminsky about adverse reactions
tion of each drug that need immediate medical attention, such as a
MRS.S sudden change in weight, nausea, loss of appe-
559 • Idenfify at least three
w t t m P H L B ' V L E " gola Of siluei Duototte (polistied edges, adverse reactions that tite, change in affect, palpitations, or lethargy
salin center). Florentine (textured]. Satin (bfushed). PallsABd (shiny) should be brought to • Provide Mrs. Kaminsky with a list of adverse re-
or Feattiercut Edge, (ettrs}. the immediate atten- actions for home use.
METAL FRflMED STYLE satin plastic nameplate set in our hand-
some regiilai gold or siluer glossed naraepin frame, or choose tion of a health care • Discuss the importance of monitoring daily
teathercut trartie at slight extra cost. practitioner weight and noting more than a 2- to 3-pound in-
PLASTIC LAMINATE Jewelers pinDack, edges match letterfng
color Finest Reeves ctattstiianship ttiroughout • Describe the impor- crease.
tance of monitoring • Provide Mrs Kaminsky with written instructions
Spragtie-Rappaport TYPE daily weight. concerning the major actions and adverse effects
• Demonstrate the of each drug as a guide for home use
STETHOSCOPE Vou cannot own a finer quality
Spragje-Rappaporl stetho- ability to take her • Include Mrs. Kaminsky's son or significant
scope' Reeves owr brand is the pulse accurately. other in the teaching if possible.
ultimate design for accuracy, • Instruct Mrs Kaminsky on methods for taking
precision-constructed for a life-
time of dependability Incfudes her pulse, using demonstration and practice.
compiefe head, diaphragm, bell,
and eartip selections Guaran- NURSING DIAGNOSIS
teed 10 years Order today Noncompliance. related to a misunderstanding of the importance of the pre-
\ FHEE ENGRAVING scribed drug regimen (includes theophylline [Theo-Dur], metaproterenol
ot name or Initials. [Alupent Inhaler], beclomethasone [Vancenase Inhaler], furosemide ffrusemide,
Lasix], potassium chloride [K-Lor], and cephalexin [Keflex])
Each 3 5 .6;1_1 12+.
MXSA311 20,95 18 86 16.75 15.71
OUTCOME CRITERIA NURSING INTERVENTIONS
TO: REEVES CO.. Boi T I S - N . Atlleboro. Mass. 0 2 7 0 3
By discharge, Mr. • Discuss emphysema with Mr. Miller, noting the
Miller will: disease process and why exacerbations occur—
• State two reasons discontinuation of his drugs, progression of his
why he has exacerba- disease or exposure to cold viruses.
Use e«trs sheet tor additional itetni or orders. tions of his emphy- • Instruct Mr Miller about the signs and symp-
FREE
ENGRAVING Desired sema toms that indicated a need for medical attention
TOORDERNAMEPINS, chf ch off your choicesmcharlBela* Print • Identify at least three before hospitalization and how to monitor the
engrflvingrtflsifeclin piflcp prcfujdefj Please submil group ordpr^ on
plain paper EncloiP yaw mailing address. Prinl clearly signs that may indicate signs, including increased shortness of breath,
exacerbations ot his increased use of oxygen, inability to perform ac-
Namepin Discounts 5-9:10% 10-14:15% 1S+: 20%
emphysema. tivities of daily living, and changes in the color of
• Verbalize the major secretions.
actions of the pre- • Discuss and provide written information on the
scribed drugs. drug actions.
• Describe the differ- • Discuss the relationship of the prescribed
ence between adverse drugs to his disease
reactions to the drugs • Discuss the difference between the adverse re-
and the signs of exac- actions to the drugs and signs and symptoms
erbations of his em- that indicate an exacerbation of his emphysema
physema. or progression of the disease state. Provide Mr.
I ENGRAVE NAMEPIN AS FOLLCWS: • Describe the rela- Miller with a list of the information
tionship between his • Contact the home health agency tor follow-up
drug regimen and his care.
emphysema. • Involve Mr. Miller's wife in the teaching ses-
• Verbalize the impor- sions.
I enclose $„ .plusS1.65han(l.;posl.T0TftLJ
Mass, residents add S% Sales Tai tance of taking his • Contact social services to assess the family
VISA. MASTEHCARD wei':oniGtt Please 5Ut>mn Card No.. ExpiiB- prescribed drugs as finances, and refer Mr Miller to hospital and
tion Date anrJ Si^nalure with oroei or Dhore 5a5-Z22-je77 ordered community resources.
Please enclose your nsme.'address with this order.

86 Nursing88. October