A systematic approach to nursing care, the nursing process helps guide you as you develop, implement, and evaluate your care and ensures that you’ll deliver consistent, effective, and safe drug therapy to your patients. The nursing process consists of five steps, including assessment, nursing diagnosis, planning, implementation, and evaluation. Even though documentation is not a step in the nursing process, you’re legally and professionally responsible for documenting all aspects of your care before, during, and after drug administration.
Assessment
The first step in the nursing process, assessment involves gathering information that’s essential to guide your patient’s drug therapy. This information includes the patient’s allergies, drug and medical history, present drug use, and physical examination findings. Assessment is an ongoing process that serves as a baseline against which to compare any changes in your patient’s condition; it’s also the basis for developing and individualizing your patient’s plan of care.
ALLERGIES
Find out if the patient is allergic to any drugs or foods. If they have an allergy, explore it further by determining the type of drug or food that triggers a reaction, the first time they experienced a reaction, the characteristics of the reaction, and other related information. Keep in mind that some patients consider annoying symptoms, such as indigestion, an allergic reaction. However, be sure to document a true allergy according to your facility’s policy to ensure that the patient doesn’t receive that drug or any related drug that may cause a similar reaction. Also, document allergies to foods because they may lead to adverse drug reactions or drug interactions. For example, sulfite is a food additive as well as a drug additive, so a patient with a known allergy to sulfite-containing foods is likely to react to sulfite-containing drugs.
DRUG HISTORY
The patient’s drug history is critical in your planning of drug-related care. Ask about their previous use of over-the-counter and prescription drugs, as well as herbal remedies. For each drug, determine:
Also determine if the patient has a history of drug abuse or addiction. Depending on their emotional and physical state, you may need to obtain the drug history from other sources, such as family members, friends, other caregivers, and the medical record.
MEDICAL HISTORY
While reviewing your patient’s medical history, determine if they have any acute or chronic conditions that may interfere with their drug therapy. Certain disorders involving major body systems, such as the cardiovascular, GI, hepatic, and renal systems, may affect a drug’s absorption, transport, metabolism, or excretion and interfere with its action; they also may increase the incidence of adverse reactions and lead to toxicity. For each disorder identified, try to determine when the condition was diagnosed, what drugs were prescribed, and who prescribed them. This information can help you determine whether the patient is receiving incompatible drugs and whether more than one prescriber is managing their drug therapy.
Ask females of childbearing age if they are or may be pregnant. Also, inquire if females of childbearing age are using a contraceptive and, if so, what type is being used. Some drugs such as isotretinoin require females of childbearing age to use an effective contraceptive, or the drug cannot be given. In other instances, the type of contraceptive used may need to be changed or a second type of contraceptive added such as with rifampin therapy. Ask mothers if they are breastfeeding. Many drugs are safe to use during pregnancy, but others may harm the fetus. Also, some drugs are distributed into breast milk. If your patient is or might be pregnant, check the FDA’s recommendation for the prescribed drug and notify the prescriber if the drug may pose a risk to the fetus. If the patient is breastfeeding, find out if the drug is distributed in breast milk and intervene appropriately.
PRESENT DRUG USE
Ask about the patient’s current use of over-the-counter and prescription drugs, as well as herbal remedies. As you did in the drug history, find out the specific details for each drug (dosage, route, frequency, and reason for taking). Also, ask the patient if they think the drug has been effective and when they took the last dose.
If the patient uses herbal remedies, explore the use of these products because herbs may interact with certain drugs. Also, ask about the patient’s use of illegal drugs, such as heroin, as well as recreational drugs, such as alcohol and tobacco. If the patient acknowledges use of these drugs, be alert for possible drug interactions. This information also may provide you with insight about the patient’s response—or lack of response—to their current drug treatment plan.
Try to find out if the patient has any other problems that might affect their compliance with the drug treatment plan and intervene appropriately. For instance, a patient who is unemployed and has no health insurance may fail to fill a needed prescription. In such a case, contact an appropriate individual in your facility who may be able to help the patient obtain financial assistance.
Be sure to ask the patient if their drug treatment plan requires special monitoring or follow-up laboratory tests. For example, patients who take antihypertensives need to have their blood pressure checked routinely, and those who take warfarin must have their prothrombin time tested regularly. Other patients must undergo periodic blood tests to assess their hepatic and renal function. Determine whether the patient has complied with this part of their treatment plan and ask them if they know the results of the latest monitoring or laboratory tests.
PHYSICAL EXAMINATION FINDINGS
As part of the physical examination, note the patient’s age and weight. Be aware that age determines the dosage of certain drugs, such as sedatives and hypnotics, whereas weight determines the dosage of others, including some I.V. antibiotics and antivirals. As you perform the physical examination, note any abnormal findings that may point to body organ or system dysfunction. For example, if you detect ascites and liver enlargement, the patient may have impaired hepatic function, which can affect the metabolism of a drug they’re taking and lead to harmful adverse or toxic effects. Also, note whether a body organ or system appears to be responding to drug treatment. For example, if a patient has been taking an antibiotic to treat chronic bronchitis, thoroughly evaluate their respiratory status to measure their progress. Be sure to assess the patient for possible adverse reactions to the drugs they’re taking.
Assess the patient’s neurologic function to make sure that they can understand their drug regimen and carry out required tasks, such as performing a fingerstick to obtain blood for glucose measurement. If the patient can’t understand essential drug information, you’ll need to identify a family member or another person who is willing to become involved in the teaching process.
Nursing Diagnosis
Based on information derived from the assessment and physical examination findings, the nursing diagnoses are statements of actual or potential problems that a nurse is licensed to treat or manage alone or in collaboration with other members of the healthcare team. They’re worded according to guidelines established by the North American Nursing Diagnosis Association (NANDA) International.
One of the most common nursing diagnoses related to drug therapy is knowledge deficit, which indicates that the patient doesn’t have sufficient understanding of their drug regimen. However, adverse reactions are the basis for most nursing diagnoses related to drug administration. For example, a patient receiving an opioid analgesic might have a nursing diagnosis of constipation related to decreased intestinal motility or ineffective breathing pattern related to respiratory depression. A patient receiving long-term, high-dose corticosteroids may have a risk for impaired skin integrity related to cortisone acetate or self-concept disturbance related to physical changes from prednisone therapy. Many antiarrhythmics cause orthostatic hypotension and thus may place an older patient at high risk for injury related to possible syncope. Broad-spectrum antibiotics, especially penicillin, may lead to the overgrowth of Clostridioides difficile, a bacterium that is normally present in the intestine. This overgrowth in turn may lead to pseudomembranous colitis, characterized by abdominal pain and severe diarrhea. The nursing diagnoses in such a case might include alteration in comfort related to abdominal pain, fluid balance deficit related to diarrhea, and potential for infection related to bacterial overgrowth.
Planning
During the planning phase, you’ll establish expected outcomes—or goals—for the patient and then develop specific nursing interventions to achieve them. Expected outcomes are observable or measurable goals that should occur as a result of nursing interventions and sometimes in conjunction with medical interventions. Developed in collaboration with the patient, the outcomes should be objective and realistic and should clearly communicate the direction of the plan of care to other nurses. They should be written as behaviors or responses for the patient, not the nurse, to achieve and should include a time frame for measuring the patient’s progress. An example of a typical expected outcome is, the patient will accurately demonstrate self-administration of insulin before discharge. Based on each outcome statement you establish, you’d then develop appropriate nursing interventions, which might include calculation of drug dosages based on weight, drug administration techniques, monitoring of vital signs, patient teaching, and recording of intake and output.
Implementation
As you implement the nursing interventions, be sure to stringently follow the classic rule of drug administration: Administer the right dose of the right drug by the right route to the right patient at the right time. Also, keep in mind that you have a legal and professional responsibility to follow institutional policy regarding standing orders, prescription renewal, and the use of nursing judgment. During the implementation phase, you’ll also begin to evaluate the nursing interventions and patient’s expected outcomes and make necessary changes to the plan of care.
Evaluation
Evaluation is an ongoing process rather than a single step in the nursing process. During this phase, you evaluate each expected outcome to determine whether it has been achieved, whether the original plan of care is working, or if it should be modified. In evaluating a patient’s drug treatment plan, you should determine whether the drug is controlling the signs and symptoms for which it was prescribed. You should also evaluate the patient for physiologic or psychological responses to the drug, especially adverse reactions. This constant monitoring allows you to make appropriate and timely suggestions for changes to the plan of care, such as dosage adjustments or changes in delivery routes, until each expected outcome has been achieved.
Documentation
You’re responsible for documenting all your actions related to the patient’s drug therapy, from the assessment phase to evaluation. And, remember it must appear on the correct medical record for the right patient. Each time you administer a drug, document the drug name, dose, time given, and your evaluation of its effect. When you administer drugs that require additional nursing judgment, such as those prescribed on an as-needed basis, document the rationale for administering the drug and follow-up assessment or interventions for each dose administered.
If you decide to withhold a prescribed drug based on your nursing judgment, document your action and the rationale for it, and notify the prescriber of your action in a timely manner. Whenever you notify a prescriber about a significant finding related to drug therapy, such as an adverse reaction, document the date and time, the person you contacted, what you discussed, and how you intervened.