Professional Documents
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Nursing Process in Administering Medications
Nursing Process in Administering Medications
I. ASSESSMENT
The first step in the nursing process; it is the systematic, organized collection of data about
the patient. Two key areas that need to be assessed are the patient’s history (past and
present illness) and his physical status
A. PAST HISTORY
B. PHYSICAL ASSESSMENT
• Noncompliance
• Knowledge deficit
III. PLANNING
Includes goal setting, setting priorities and determining nursing interventions
For medications, planning includes activities as discussing the client’s medication needs
Nurses also formulate instructional objectives and design client education programs to assist
individuals in the self-administration of drugs
In planning, focus on:
• Drug Interactions
IV. IMPLEMENTATION
Includes the nursing actions necessary to accomplish the established goals. Client education
and teaching is our primary responsibility
For drug therapy, implementation includes all aspects of medication administration (working
with the doctor, giving drugs as prescribed, preparing drugs, calculating dosages, using
appropriate admin techniques, staying alert for errors, documenting the drugs given)
– Drug administration
– Patient/family education
• 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
• 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, wrong
route of administration, and miscalculation of dosages; take care to avoid these errors
Comfort Measures
• Placebo effect
• Lifestyle adjustment
• Timing of administration
Nursing implications
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 the
effects have been insufficient, which issues may be involved?
RIGHT CLIENT
• Check ID bracelet
RIGHT DRUG
• Means that the right client receives the drug that was prescribed
• For hospitalized clients, the drug orders are written on the “doctor’s order sheet” and
signed by the duly authorized person
• A telephone order (TO) for medications must be cosigned by the physician within 24 hours
• Drug name
• Drug dosage
• Route of administration
• Frequency of administration
• Standing order- protocols derived from guidelines created by healthcare providers for
use in specific settings, for treating certain diseases or sets of symptoms
• Standard order- may be an ongoing order, may be given for a specific number of doses
or days. May include prn orders
• One time or single order- given once and usually at a specific time
• PRN orders- given at the client’s request and nurse’s judgment concerning need and
safety
• Stat orders- given once immediately
RIGHT DOSE
NURSING IMPLICATION:
• Be familiar with the various measurement system and the conversion from one system to
another
Measuring devices:
• Medication cups
• Dropper
• Syringe
– Tuberculin
– Insulin
– General purpose
Nursing Implication:
• Always measure the volume of a liquid medication at the lowest point of the meniscus
• When measuring drops of medication with a dropper, always hold the dropper vertically
and close to the medication cup
• Do not attempt to divide unscored tablets and do not administer tablets which have been
broken unevenly along the scoring
• When removing a drug from a multiple dose vial, wipe the stopper on the vial with an
alcohol sponge
• Inject an amount of air into the vial equal to the volume of fluid to be removed and
withdraw the required amount of liquid
• If there are air bubbles in the syringe, these must be removed by holding the syringe with
the needle toward the ceiling and tapping the syringe with your finger to move the air
bubbles toward the hub. They should be expelled by gently pushing on the plunger.
• When medication is in a glass ampule, flick the top of the ampule to be sure all medication
is in the larger bottom portion. Wrap the neck of the ampule with dry gauze pad and snap
off the top
RIGHT ROUTE
• Includes the correct route of administration, and administration in such a way that the
client is able to take the entire dose of the drug and receive maximal benefit from it
Nursing implications
• If no route is specified in the order, the prescribing physician should be questioned about
the intended route
• Always gain the client’s cooperation, before attempting to administer a dose of medication
RIGHT TIME
Nursing Implication
• Administer drugs that are affected by foods, such as tetracycline and penicillin before
meals
• Administer drugs such as potassium and aspirin after meals or with food
• It is the nurse’s responsibility to check whether the client is scheduled for diagnostic
purposes such as endoscopy, fasting blood sugar etc.
• Check the expiration date. Discard the medication or return to pharmacy if the date is
passed
RIGHT DOCUMENTATION
• Requires that the nurse immediately record the appropriate information about the drug
administered
• right documentation includes the drug, dosage, route, time, and the client’s response
Nursing implication:
• Right documentation as not only a legal requirement but also a safety responsibility of the
nurse
• This right is a principle of informed consent which is based on the individual’s having the
knowledge to make a decision
• Name of medication
• Purpose of medication
NURSING IMPLICATIONS:
• If knowledge deficit underlies client’s reason for refusal. Provide appropriate explanation
for why medication is ordered