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Nursing Process in Administering Medications

Nursing Process in Administering Medications

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Published by Lady Mae Ramos

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Published by: Lady Mae Ramos on Sep 03, 2010
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05/23/2013

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NURSING PROCESS IN ADMINISTERING MEDICATIONS
I. ASSESSMENT
 The first step in the nursing process; it is the systematic, organized collection of data aboutthe patient. Two key areas that need to be assessed are the patient’s history (past andpresent illness) and his physical status
A. PAST HISTORY 
Chronic conditions
Drug use
Allergies
Level of education
Social support
Financial support
Pattern of health care
Level of understanding of disease andtherapy
Previous medical record
B. PHYSICAL ASSESSMENT
Weight
Age
Vital signs
Sensory and cognitive barriers
II. NURSING DIAGNOSIS
Shows actual or potential alterations in patient’s function based on the assessment of theclinical situationCommon Nursing Diagnoses r/t Drug Therapy:
Ineffective health maintenance
Risk for injury
Noncompliance
Knowledge deficit
Ineffective management of therapeutic regimen
III. PLANNING
Includes goal setting, setting priorities and determining nursing interventionsFor medications, planning includes activities as discussing the client’s medication needsNurses also formulate instructional objectives and design client education programs to assistindividuals in the self-administration of drugs
 
In planning, focus on:
Why the drug is needed
How the drug is administered
Common indications of adverse effects
Best schedule to administer the drug
Drug Interactions
IV. IMPLEMENTATION
Includes the nursing actions necessary to accomplish the established goals. Client educationand teaching is our primary responsibilityFor drug therapy, implementation includes all aspects of medication administration (workingwith the doctor, giving drugs as prescribed, preparing drugs, calculating dosages, usingappropriate admin techniques, staying alert for errors, documenting the drugs given)3 types of interventions frequently involved in drug therapy:
 – 
Drug administration
 – 
Provision of comfort measures
 – 
Patient/family educationProper Drug Administration Guidelines
Administer medications as prescribed
Never give a drug poured or prepared by somebody else
Never allow the med cart or tray out of your sight once you have prepared a dose
Never leave a drug at a patient’s bedside; rather watch the patient swallow the drug
Never return unwrapped or prepared drugs to the stock supply
Keep the medication cart locked at all times
Follow standard precautions as appropriate
Consider legal aspects associated with drug therapy
Consider ethical principles when dealing with medication errors, meds during pregnancy,and investigational protocols
Medication errors can easily be caused by similar sounding names, unclear orders, wrongroute of administration, and miscalculation of dosages; take care to avoid these errors
 
Comfort Measures
Placebo effect
Manage anticipated adverse
Lifestyle adjustmentPatient and Family Education
Name, dose and action of the drug
 Timing of administration
Special storage and preparation instruction
Specific OTC drugs or alternative therapies to avoid
Special comfort and safety measures
Specific points about drug toxicity
Specific warning about drug discontinuationAdditional teaching tips:
Provide written instructions
Use colorful graphs and charts
Encourage client and family to ask questionsNursing implications
Ensure cleanliness of your hands, work area, and supplies
Ensure availability of supplies
Ensure adequate lighting
Decrease environmental distractions
V. EVALUATION
Comparing the patient’s therapeutic goals with his actual response to drug therapy
in this phase, the nurse must be able to answer the following questions:
 – 
What therapeutic effects should the drug produce?
 – 
What adverse reactions is the drug known to cause?
 – 
By what mechanism of action does the drug work?
 – 
What should the patient know about the drug
 – 
Which therapeutic effects has the drug produced for the patient? If none, or if theeffects have been insufficient, which issues may be involved?
12 “RIGHTS” OF DRUG ADMINISTRATION

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