An ongoing assessment is one that is made at the time of each patient contact and may include the collection of objective data, subjective data, or both. The scope of an ongoing assessment depends on many factors, such as the patient’s diagnosis, the severity of illness, the response to treatment, and the prescribed medical or surgical treatment.
The assessment phase (including the initial and ongoing assessment) of the nursing process can be applied to the administration of drugs, with objective and subjective data collected before and after to obtain a thorough baseline or initial assessment. This allows subsequent assessments to be compared with the baseline information. This comparison helps to evaluate the effectiveness of the drug and the presence of any adverse reactions. Ongoing assessments of objective and subjective data are equally important when administering drugs. Important objective data include blood pressure, pulse, respiratory rate, temperature, weight, appearance of the skin, appearance of an intravenous infusion site, and pulmonary status as assessed by auscultation of the lungs. Important subjective data include any statements made by the patient about relief or nonrelief of pain or other symptoms after administration of a drug.
The extent of the assessment and collection of objective and subjective data before and after a drug is administered depends on the type of drug and the reason for its use.
Analysis is the way nurses cluster data into similar groupings to determine patient need. The data collected during assessment are examined for common threads; the nurse identifies the patient’s needs (problems) and formulates one or more nursing diagnoses. A nursing diagnosis is not a medical diagnosis; rather, it is a description of the patient’s problems and their probable or actual related causes based on the subjective and objective data in the database.
A nursing diagnosis identifies problems that can be solved or prevented by independent nursing actions—actions that do not require a physician’s order and may be legally performed by a nurse. Nursing diagnoses provide the framework and consistent language for selection of nursing interventions to achieve expected outcomes.
The North American Nursing Diagnosis Association-International (NANDA-I) was formed to standardize the terminology used for nursing diagnoses. NANDA-I continues to define, explain, classify, and research summary statements about health problems related to nursing. NANDA-I has approved a list of diagnostic categories to be used in formulating a nursing diagnosis. This list of diagnostic categories is periodically revised and updated.
In some instances, nursing diagnoses may apply to a specific group or type of drug or a particular patient. One example is Deficient Fluid Volume related to active fluid volume loss (diuresis) secondary to administration of a diuretic. Specific drug-related nursing diagnoses are highlighted in each chapter. However, it is beyond the scope of this book to individualize care and provide every nursing diagnosis that you may use for all patients you may encounter related to a drug or a drug class.
Some of the nursing diagnoses developed by NANDA-I may be used to identify patient problems associated with drug therapy and are more commonly used when administering drugs. The most frequently used nursing diagnoses related to the administration of drugs include:
• Effective Self Health Management
• Ineffective Self Health Management
• Deficient Knowledge
Because these nursing diagnoses are commonly used when all types of drugs are administered, they will not be repeated for each chapter. Keep these nursing diagnoses in mind when administering any drug. Expansion of nursing actions corresponding to these nursing diagnoses is featured later in this chapter.
After the nursing diagnoses are formulated, a patient-oriented goal and expected outcomes are developed for each nursing diagnosis. The goal statement is a broad expectation that will indicate the problem is resolved. An expected outcome is a direct statement of how patient goals are to be achieved. The expected outcome describes the maximum level of wellness that is reasonably attainable for the patient. For example, common expected patient outcomes related to drug administration, in general, include:
• The patient will effectively manage the drug regimen.
• The patient will understand the drug regimen.
• The patient will comply with the drug regimen.
The expected outcomes define the behavior of the patient or family that indicates the problem is being resolved or that progress toward resolution is occurring.
Selecting the appropriate interventions is based on the expected outcomes that help to develop a plan of action or patient care plan. Planning for nursing actions specific to the drug to be administered can result in greater accuracy in drug administration, enhanced patient understanding of the drug regimen, and improved patient adherence to the prescribed drug therapy after discharge from the hospital. For example, during the initial assessment interview, the patient may report an allergy to penicillin. This information is important, and you must now plan the best methods of informing all members of the health care team of the patient’s allergy to penicillin.
The planning phase describes the steps for carrying out nursing activities or interventions that are specific and that will meet the expected outcomes. Planning anticipates the implementation phase or the carrying out of nursing actions that are specific to the drug being administered. If, for example, the patient is to receive a drug by the intravenous route, you must plan for the materials needed and the patient instruction for administration of the drug by this route. In this instance, the planning phase occurs immediately before the implementation phase and is necessary to carry out the technique of intravenous administration correctly. Failing to plan effectively may result in forgetting to obtain all of the materials necessary for drug administration.
Implementation is the carrying out of a plan of action and is a natural outgrowth of the assessment and planning phases of the nursing process. When related to the administration of drugs, implementation refers to the preparation and administration of one or more drugs to a specific patient. Before administering a drug, review the subjective and objective data obtained on assessment and consider any additional data, such as blood pressure, pulse, or statements made by the patient. The decision of whether to administer the drug is based on an analysis of all information. For example, a patient is hypertensive and is supposed to receive a drug to lower the blood pressure. Objective data obtained at the time of admission (baseline) included a blood pressure of 188/110. Additional objective data obtained immediately before the administration of the drug (ongoing) included a blood pressure of 182/110. A decision is made by the nurse to administer the drug because the change in the patient’s blood pressure is minimal. However, if the patient’s blood pressure is 132/84, and this is only the second dose of the drug, the nurse could decide to withhold the drug and contact the prescribing health care provider. Giving or withholding a drug and contacting the patient’s health care provider are nursing activities related to the implementation phase of the nursing process.
The more common nursing diagnoses used when administering drugs are Effective Self Health Management, Ineffective Self Health Management, Deficient Knowledge, and Noncompliance. Nursing interventions applicable to each of these nursing diagnoses are discussed in the following sections. However, each patient is an individual, and nursing care must be planned on an individual basis after a careful collection and analysis of the data. In addition, each drug is different and may have various effects in the body. (For drugs discussed in subsequent chapters, some possible nursing diagnoses related to that specific drug are featured.)
Effective Self Health Management
This nursing diagnosis takes into consideration that the patient is willing to participate and integrate into daily living the treatment of an illness, such as the self-administration of medications. For this nursing diagnosis to be used, the patient verbalizes the desire to manage the medication schedule. When the patient is willing and able to manage the treatment activities, he or she may simply need information concerning the drug, method of administration, what type of reactions to expect, and what to report to the primary health care provider. A patient willing to take responsibility may need you to develop a teaching plan that gives the patient the information needed to manage the treatment activities properly (see Chapter 5 for more information on educating patients).
Ineffective Self Health Management
NANDA-I defines Ineffective Self Health Management as “a pattern of difficulty integrating into daily living a program for treatment of illness and the sequelae of illness.” In the case of medication administration, the patient may not be taking the medication correctly or following the medication schedule prescribed by the primary health care provider.
The reasons for not following the drug routine vary (Display 4.1). For example, some people do not fill their prescriptions because they do not have enough money to pay for them. Other patients skip doses, take the drug at the wrong times, or take an incorrect dose. Some may simply forget to take the drug; others take a drug for a few days, see no therapeutic effect, and quit.
When working with a patient who is not managing the drug routine correctly, assess the patient’s level of health literacy (see Chapter 5). If possible, allow the patient to administer the drug before the patient is dismissed from the health care facility. Determine if adequate funds are available to obtain the drug and any necessary supplies. For example, when a bronchodilator is administered by inhalation, a spacer or extender may be required for proper administration. This device is an additional expense. A referral to the social services department of the institution may help the patient when finances are a problem.
Display 4.1 Possible Causes of Ineffective Self-Health Management
• Extended therapy for chronic illness causes patient to become discouraged
• Troublesome adverse reactions
• Lack of understanding of the purpose for the drug
• Misunderstanding of oral or written instructions on how to take the drug
• Weak nurse–patient relationships
• Lack of funds to obtain drug
• Mobility problems
• Lack of family support
• Cognitive deficits
• Visual or hearing defects
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