Pharmacology .

NURSING PROCESS IN PHARMACOLOGY

Transcribed by: Donna Marie D. Tariman

NURSING PROCESS >

One of the most significant advances in by taking a health history, performing a
nursing has been the development of the physical examination, and reviewing
nursing process. The nursing process guides pertinent laboratory and diagnostic
nursing decisions about drug administration information. The health history includes
to ensure the patient’s safety and to meet documenting drugs and herbal preparations
medical and legal standards. The five steps that the patient is taking as well as any
of the nursing process are dynamic, flexible, allergies (Berry et al., 2016).
and interrelated (Berry et al., 2016). They
include:
 Assessment
 Nursing Diagnosis
 Planning
 Implementation
 Evaluation

During the assessment, the nurse collects a

comprehensive information base about the
patient from the physical examination, the
nursing history, the medication history, and
professional observations. Formats
commonly used for data collection,
organization, and analysis are the head-to-
toe assessment, body systems assessment,
and Gordon’s Functional Health Patterns
Model. The head-to-toe and body systems
approaches focus on the patient’s
physiology, whereas the Gordon’s
Functional Health Patterns Model includes
sociocultural, psychological, spiritual, and
developmental factors that affect the
ASSESSMENT > individual’s needs. Box 4-2 shows Gordon’s
Assessment involves collecting data that are Functional Health Patterns Model (Clayton,
used to identify the patient’s actual and 2016).
potential health needs. You can obtain data
 PLANNING >
After you establish a nursing diagnosis,
you’ll develop a written care plan. A written
care plan serves as a communication tool
among health care team members that helps
ensure continuity of care. The plan consists
of two parts: patient outcomes, or expected
outcomes, which describe behaviors or
results to be achieved within a specific time
nursing interventions needed to achieve
those outcomes (Berry et al., 2016).

NURSING DIAGNOSIS >

NANDA International defines the nursing
diagnosis as a “clinical judgment about
individual, family, or community responses IMPLEMENTATION >
to actual or potential health problems or life
processes.” It goes on to say that “Nursing The implementation phase is when you put
diagnoses provide the basis for the selection your care plan into action. Implementation
of nursing interventions to achieve encompasses all nursing interventions,
outcomes for which the nurse is accountable including drug therapy, that are directed
(Berry et al., 2016). toward meeting the patient’s health care
needs. While you coordinate
implementation, you collaborate with the
patient and the patient’s family and consult
with other caregivers. Implementation can
involve a multidisciplinary approach,
depending on the needs of the patient and
his family (Berry et al., 2016)

DRUG ADMINISTRATION >

A drug’s administration route influences the
quantity given and the rate at which the drug
is absorbed and distributed. These variables
affect the drug’s action and the patient’s
response.
  Name of the person
 Strength and dosage
 Frequency against the
o Medical order
o MAR and
o Medication container.
 Verify any medication order and
make sure it’s complete. The order
should include the drug name,
dosage, frequency and route of
administration.
 Check the patient's medical record
for an allergy or contraindication to
the prescribed medication. If an
allergy or contraindications exist,
MEDICATION ORDERS >
don't administer the medication and
 Routine orders notify the practitioner.
 PRN orders  Prepare medications for one patient
 One time orders at a time. Educate patients about
 STAT orders their medications.

ROUTINE MEDICATION ORDERS > SEVEN RIGHTS >

 Detailed order for a medication 1. Right Individual.
given on a routine or regularly o Collecting medication for only one
scheduled basis such as every individual at a time.
morning at 10 AM o If there is any doubt that you are
giving a medication to the wrong
person, don’t give the medication
PRN MEDICATION (AS NEEDED) ORDERS > until you are sure you are giving to
the correct individual.
 A medication which is ordered to be
2. Right Medication.
given “when necessary” or “as
o This involves reading the med label
needed” within a designated number
on the bottle, including the brand
of hour
name of the medication and the
generic name of the medication (if
ONE TIME ORDERS > both are available).
o Make use of the nursing supervisor so
 Some medications to be given only
that you are not the only one
once and are ordered to be given at a
questioning the right medication.
specific time and then discontinued.
3. Right Dose
o Be aware of the strength of each
STAT ORDERS > medication you are giving.
o Ask the pharmacist or the nursing
 These medications need to be given supervisor any time your calculations
immediately or NOW indicate that you need to give three or
more pills of the same medication at
the same time as this is when
MEDICATION SAFETY > medication errors are most likely to
 Remember the three checks occur.
o Checking the: 4. Right Time.
 o Some medications need to be given at after application of the nursing process, the
the same time every day or at the client’s condition or well-being improves.
same time with relationship to the The nurse applies all that is known about a
patient’s mealtime. client and the client’s condition, as well as
o In general, you need to give the experience with previous clients, to
medication within one-half hour of evaluate whether nursing care was effective.
when it is supposed to be given The nurse conducts evaluation measures to
(before or after the correct time). determine if expected outcomes are met, not
5. Right Route. the nursing interventions.
o This involves where and how the
medication is given to the patient.
The medication may be given by The expected outcomes are the standards
rectum, through the skin, in the eyes, against which the nurse judges if goals have
in the ears, into the lungs, or into the been met and thus if care is successful.
vagina. Providing health care in a timely, competent,
o If the patient has an NG tube, make and cost- effective manner is complex and
sure the medication fits down the challenging. The evaluation process will
tube and crush it only if the determine the effectiveness of care, make
pharmacist says it is okay to crush the necessary modifications, and to
medication. continuously ensure favourable client
6. Right documentation: outcomes (Evaluation, n.d.)
o You need to do this documentation at
the time it is being administered and
not any other time before or after
that.
o Use blue or black ink to make your
notes and never use a pencil or white
out if you make an error.
7. Right Response.
o Make sure you document the
response the patient has to the
medication.
o For example, if the medication is a
pain medication, you need to
document the degree to which the
medication alleviated the pain.

EVALUATION > “For those who exalt themselves will be

Evaluation, the final step of the nursing humbled, and those who humble themselves
process, is crucial to determine whether, will be exalted.” – Matthew 23: 1