THE NURSING

PROCESS IN
`
DRUG
THERAPY
Module III
Regie De Jesus, MAN
College of Health Sciences
Pharmacology
Nursing Process in Drug Therapy
• nursing process—a decision-making, problem-
solving process—to provide efficient and
effective care.
• Ensures the patient receives the best, safest, most
efficient, scientifically based, holistic care.
• Nurses must consider how a person responds to
disease and its treatment, including the changes
in lifestyle that may be required.
Nursing Process in Drug Therapy
• assess the whole patient, to administer
therapy as well as medications, to teach the
patient how best to cope with the therapy
• integrating knowledge of the basic sciences
the social sciences, education, and many other
disciplines in the nursing process.
Assessment
A. Past History
a. Chronic Conditions
• affects pharmacokinetics and
pharmacodynamics
b. Drug use
• The possible presence of other drugs that
may interact with medication to be given.
Assessment
A. Past History
c. Allergies
• Past exposure to a drug or other allergens can
provoke a future reaction or necessitate the
need for cautious
d. Level of Education and Understanding
e. Social Support
• Often patients need help at home with care and
drug therapy.
Assessment
A. Past History
f. Financial Support
• Financial constraints may cause a patient not to
follow through with a prescribed drug regimen.
g. Patterns of Health Care
• Knowing how a patient seeks health care
provides the nurse with valuable information to
include when preparing the patient’s teaching
plan.
Assessment
B. Physical Examination
a. Age
• children and older adults often require dose
adjustments
b. Physical parameters related to the Disease
and Drug Effects
• depend on the disease process being treated and
on the expected therapeutic and adverse effects
of the drug therapy.
 Assessment B. Physical
Examination
c. Possibility of Pregnancy
Category Description Examples
No risk in controlled human studies: Adequate and well-controlled Folic Acid
A human studies have failed to demonstrate a risk to the fetus in the Levothyroxine
(SAFEST) first trimester of pregnancy (and there is no evidence of risk in later Doxylamine
trimesters).
Insulin
No risk in other studies: Animal reproduction studies have failed to Prednisone
demonstrate a risk to the fetus and there are no adequate and well- Amoxicillin
B controlled studies in pregnant women, or animal studies have shown Loratadine
adverse effects, but adequate and well-controlled studies in pregnant Ondansetron
women have failed to demonstrate a risk to the fetus in any
trimester.
Prozac
Risk not ruled out: Animal reproduction studies have shown an Sertraline (Zoloft)
adverse effect on the fetus and there are no adequate and well- Metroprolol
C controlled studies in humans, but potential benefits may warrant use  
of the drug in pregnant women despite potential risks.
 Assessment B. Physical
Examination
c. Possibility of Pregnancy
Examples
Category Description
Ibuprofen after
Positive evidence of risk: There is positive evidence of human fetal risk 30 weeks
based on adverse reaction data from investigational or marketing Phenytoin
D experience or studies in humans, but potential benefits may warrant Lithium
use of the drug in pregnant women despite potential risks.
Methotrexate
Contraindicated in pregnancy: Studies in animals or humans have Atorvastatin
demonstrated fetal abnormalities and/or there is positive evidence of (Lipitor)
X human fetal risk based on adverse reaction data from investigational or Simvastatin
marketing experience, and the risks involved in use of the drug in Warfarin
pregnant women clearly outweigh potential benefits.
 
N or NR FDA has not yet classified the drug into a specified pregnancy category.
UPDATE on Pregnancy Categories
• Replaced pregnancy risk Letters with new
information to make them more meaningful
to both patients and healthcare providers.
• Pregnancy and Lactation Labeling Final
Rule (PLLR) went into effect on June 30,
2015
Pregnancy and Lactation Labeling
Final Rule (PLLR) 
Pregnancy and Lactation Labeling
Final Rule (PLLR) 
• still does not provide a definitive “yes” or
“no” answer in most cases.
• Clinical interpretation is still required on a
case-by-case basis.
NURSING DIAGNOSIS
• shows actual or potential alterations in
patient function
• Nursing diagnoses that are related to drug
therapy must be incorporated into a total
picture of the patient.
• refer to the North American Nursing
Diagnosis Association (NANDA-I) for a list
of accepted nursing diagnoses
PLANNING AND
IMPLEMENTATION
• setting goals and desired patient outcomes to
assure safe and effective drug therapy
• In this phase, the nurse decides how to render
care related to medication administration.
• Included in this phase are:
• drug administration,
• provision of comfort measures, and patient/family
education
• 
Ten (10) RIGHTS of
Safe Medication
Administration.
10 RIGHTS of Safe Medication
Administration.
RIGHT PATIENT
• Always check patient’s identification bracelet.
• Avoid the error of asking a patient, “Are you Mr.
Khufra?”
• Ask patient to state their name and birth date.
• Rely on the patient telling you his/her name and
read it from the identification band.
• Compare medication order to identification
bracelet and patient’s stated name and birth date.
• Verify patient’s allergies with chart and with
patient.
10 RIGHTS of Safe Medication
Administration.
RIGHT MEDICATION/DRUG
• Any drugs may look alike and or have sound-
alike names.
• Make sure the drug makes sense for the patient
for whom it is ordered.
• Perform a triple check of the medication’s label
• When retrieving the medication.
• When preparing the medication.
• Before administering medication to patient .
• RIGHT MEDICATION/DRUG
• Before administering medication to patient.
• Always check the medication label with the
physician’s orders.
• Never administer medication prepared by
another person
• Never administer medication that is not labeled.
10 RIGHTS of Safe Medication
Administration.
RIGHT DOSE
• Check label for medication concentration.
• Compare prepared dose with medication order.
• Triple check all medication calculations.
• Check all medication calculations with another person
• Verify that dosage is within appropriate dose range for
patient and medication.
• Do not cut tablets to get to a correct dose without
checking to make sure the tablet can be cut, crushed,
or chewed.
Right Dose
• Be very cautious if you see an order that
starts with a decimal point; these orders are
often the cause of medication errors. You
should never see .5 mg as an order because it
could be interpreted as 5 mg, 10 times the
ordered dose.
10 RIGHTS of Safe Medication
Administration.
RIGHT TIME
• Verify schedule of medication with order.
• 1. Date
• 2. Time
• 3. Specified period of time
• Check last dose of medication given to patient.
• Recognize that the administration of one drug may
require coordination with the administration of other
drugs, foods, or physical parameters.
• Administer medication within 30 minutes of schedule.
10 RIGHTS of Safe Medication
Administration.
RIGHT ROUTE
• Verify medication route with medication order before
administering.
• Medication may only be administered via route
specified in order.
• Nurses can often have an impact in modifying the route
to arrive at the most efficient, comfortable method for
the patient
• For example, perhaps a patient is having trouble
swallowing, and a large capsule would be very difficult for
the patient to handle. The nurse could check and see if the
drug is available in a liquid form and bring this information
to the attention of the person prescribing the drug
10 RIGHTS of Safe Medication
Administration.
RIGHT EDUCATION
• Inform patient of medication being
administered.
• Inform patient of desired effects of medication.
• Inform patient of side effects of medication.
• Ask patient if they have any known allergies to
medication.
10 RIGHTS of Safe Medication
Administration.
RIGHT TO REFUSE
• The legally responsible party (patient, parent, family
member, guardian, etc.) for patient’s care has the right
to refuse any medication.
• Inform responsible party of consequences of refusing
medication.
• Verify that responsible party understands all of these
consequences.
• Notify physician that ordered medication and
document notification.
• Document refusal of medication and that responsible
party understands
10 RIGHTS of Safe Medication
Administration.
RIGHT ASSESSMENT
• Properly assess patient and tests to determine if
medication is safe and appropriate.
• If deemed unsafe or inappropriate, notify
ordering physician and document notification.
• Document that medication was not
administered and the reason that dose was
skipped.
10 RIGHTS of Safe Medication
Administration.
RIGHT EVALUATION
• Assess patient for any adverse side effects.
• Assess patient for effectiveness of medication.
• Compare patient’s prior status with post
medication status.
• Document patient’s response to medication
10 RIGHTS of Safe Medication
Administration.
RIGHT DOCUMENTATION
• Never document before medication is
administered.
• Document
• Medication and Dosage
• Route
• Date and Time
• Signature and credentials
Routes of Medication
Administration
Oral
• pills, tablets, capsules, caplets, and liquids are
administered through the oral route.
• these agents also are called p.o or PO (per orem or by
mouth) medication.
• sublingual and buccal medication are also considered
to be PO.
Oral
• when drugs are given into the GI tract but
bypass the mouth the oral drug preparation
are used.
• be sure the patient has an adequate level of
consciousness to prevent aspiration.
• the presence of pathology in the GI tract may
hinder the client’s ability to absorb
medication.
Oral
• consider the presence or absence of food in the
stomach and how this affects the medications.
• Have patient sit upright when not contraindicated.
• When giving oral medications, follow these
guidelines:
• wash hands
• do not touch the medications.
• crush only medication that can be crushed and split
only scored tablets.
• make sure the client is awake, is upright and can
swallow.
Oral
• Enteric coated – absorbed in the alkaline
environment e.g. Ecotrin (aspirin)
• Sustained release - releases medication at a
controlled rate until it is either all absorbed or
passes in the feces. E.g. niacin,
• Do Not Break
• Beads or Granules
Oral
• when giving medications through a
gastrostomy tube, wear gloves, make sure the
medication is appropriately diluted, and check
that the tube is in place. Flush tube with water
before and after administration of
medications.
Withdraw the plunger while observing for the presence
of gastric fluid or contents.
Instill the medication into the gastric tube.
Gently inject the saline.
Clamp off the distal tube.
Parenteral
Parenteral
• Drug administration outside of the gastrointestinal
tract
• are administered by injection of any kind,
including SC, ID, IM, and IV.
• other parenteral routes of medication
administration not usually administered by a nurse
include intraventricular, intra-arterial,
intracardiac, intraperitoneal, intrathecal, and
intrapleural.
Parenteral
• When giving parenteral medications, the nurse
must follow these guidelines:
• wash hands
• don gloves
• assess and identify possible detriments to absorption
such as poor circulation.
• select the appropriate site.
• know your medications
• note that parenteral medications are limited in the
volume that can be delivered.
Parts of a Syringe and Needle

Bevel
Kinds of Parenteral Drug Containers
• Glass ampules
• Vials
• Non-constituted vials
• Intravenous medication fluids
• Prefilled syringes
Parenteral
• nonconstituted drug vial actually consists of two
vials, one containing a powdered medication and
one containing a liquid mixing solution.
Ampules and Vials
Vials
Ampules
 Injection Information
Type Angle Gauge Length Syringe Nursing Considerations

ID 15o 26-27 3/8 -5/8 in Tuberculin Area must be marked or mapped

if repeated tests done.

SubQ 45o 23-25 5/8 – ½ in Tuberculin/ Insulin Rotate sites.

(1-3mL)

IM 90o 20-23 1 -1 ½ in 2-3 mL Rapid insertion and slow injection

help to decrease pain.
Aspirate and massage

IV 25o 20-21   Bag with tubing Monitor site and needle

placement.
Blood   16-18   Bag with tubing Check equipment, needle
placement and injection site
regularly.
Parenteral
• know which type of delivery system to use
and how to prepare the medication in the
correct delivery system.
• Use aseptic procedures at all time.
• SC medications should never be greater than
1 mL; IM medications must never be
delivered into a muscle in volume greater
than 3 mL.
Parenteral
• IV medications can be given
using di
• rect bolus method or drip
method
• IVPB (piggyback) and IV
continuous drip method must
be administered via an infusion
pump to ensure adequate dose.
Parenteral
• Never mix IV medications without being
absolutely sure that the medication can
safely be mixed together.
• The gauge of a needle is the diameter of the
needle. Gauges can vary from very small
diameter (25 to 29 gauge) to large diameter
(18 to 22 gauge). 
Injection Sites
• Intradermal: ventral forearm, upper chest,
shoulder.
• Sc: outer aspects of the arms and thighs, hip and
lower abdomen, above the iliac crest.
• IM: ventrogluteal, deltoid, dorsogluteal, vastus
lateralis, rectus femoris.
• Z-track is an IM technique used for solutions that
are especially staining or irritating.
• IV: lower arm and hand, upper arm, antecubital
fossa.
Parenteral Routes
Intradermal
Subcutaneous Injection Sites
Intramuscular Injection Sites
Intramuscular Injection Sites
Z-track Method
of IM injection
Other Routes
Respiratory Drug Administration
• Medications are administered into the
pulmonary system
• Instillation
• Inhalation
• Instruct the client on how to use and clean the
equipment.
• turboinhaler, metered-dose nebulizer, vaporizer,
intermittent positive-pressure breathing (IPPB)
Small volume nebulizer
Nebulizer with
attached face mask,
bag-valve mask,
and endotracheal
tube
Metered dose inhaler
Topical
• Absorbed through the skin at a slow, steady rate
(e.g. nitroglycerin patch)
• Clean administration site
• Apply medication (If the client has excessive hair
where the patch is to be applied, the area should be
shaved first.)
• Leave medication in place for required time.
Monitor the patient for desirable or adverse effects.
• be sure to date a patch when applied.
• be sure to date and time a dressing when applied.
Nitroglycerin Patch
Eye medication administration
• when administering medication in the eye, the
client’s position is very important.
• place the client in the supine position, and have the
client look upward.
• with the lower lid everted, hyperextend the client’s
neck.
• DO NOT TOUCH the dropper or applicator for the
ointment, or clean technique will be interrupted.
• Apply the medication as directed (irrigation, drops,
ointment)
Eye Drop Administration
Use a medication dropper to place the
prescribed dosage on the conjunctival sac.
Ear medication administration
• for adults, pull the pinna up and backward; for
children, pull the pinna back and down.
• DO NOT TOUCH THE DROPPER. (e.g.
irrigation, drops)
• Instruct the client to lie with head turned to the
unaffected side.
• Apply eardrops so that the medication slides down
the ear canal.
• Have the client stay in position for 5 minutes.
Aural/ Otic Medication Administration
Manually open the ear canal and administer the
appropriate dose.
Vaginal Medication Administration
• often the client will administer this herself.
• offer or apply a sanitary pad for comfort.
• make sure that client knows how to use,
clean, and maintain the applicator
• examples are irrigation, suppository, cream,
ointment, tablet, gel
Vaginal Suppository
Rectal Medication Administration
• The rectum’s extreme vascularity promotes
rapid drug absorption.
• Avoids first pass effect
• Example is suppository
• The client may wish to self-administer this
medication.
• Instruct the client how to use KY lubricating jelly.
• Instruct client to resist the urge to bear down and
to retain the medication for at least 30 minutes.
Rectal
Suppositor
y
NURSES’ ROLE IN COMFORT
MEASURES DURING DRUG THERAPY
• Placebo Effect
• The anticipation that a drug will be helpful
(placebo effect) has proved to have tremendous
impact on the actual success of drug therapy.
• For example, a back rub, a kind word, and a
positive approach may be as beneficial as the
drug itself.
NURSES’ ROLE IN COMFORT
MEASURES DURING DRUG THERAPY
• Managing Adverse Effects
• Interventions can be directed at promoting
patient safety and decreasing the impact of the
anticipated adverse effects of a drug.
• Such interventions include environmental
control (e.g., temperature, light), safety
measures (e.g., avoiding driving, avoiding the
sun, using side rails), and physical comfort
measures (e.g., skin care, laxatives, frequent
meals).
NURSES’ ROLE IN COMFORT
MEASURES DURING DRUG THERAPY
• Lifestyle Adjustment
• Some medications and their effects require that a
patient make changes in his or her lifestyle.
• For example, patients taking diuretics may have
to rearrange their day so as to be near toilet
facilities when the drug action peaks.
Module Requirement
• Please answer module 3 activity in pages 37
and 38