THE NURSING PROCESS

Nurses use the nursing

process—a decision-making,
problem-solving process—to
provide efficient and effective
care. The key elements of the
nursing process are: assessment,
nursingdiagnosis,
implementation, and evaluation.

Application of the nursing process

with drug therapy ensures that
the patient receives the best,
safest, most efficient,
scientifically based, holistic care.
 1. ASSESSMENT
the first step of the nursing
processinvolvessystematic,
organized collection of data about
the patient. Because the nurse is
responsible for holistic care, data
mustincludeinformationabout
physical,intellectual,emotional,
social, and environmental factors.
Past history
• Chronic conditions
• Drug use
• Allergies
• Level of education
• Level of understanding
of disease and therapy
• Social supports
• Financial supports
• Pattern of health care
Past History:
Is important before beginning
drug therapy, this will help
promote safe and effective use
of the drug and prevent
adverse effects.
Chronic conditions: affect
the pharmacokinetics and
pharmacodynamics of a drug.
For example, certain
conditions (e.g., renal disease,
heart disease, diabetes,
chronic lung disease) may be
contraindicated to the use of
a drug.
Drug Use: Prescription
drugs, over-the-counter
(OTC) drugs, street drugs,
alcohol, nicotine, alternative
therapies, and caffeine may
have an impact on a drug’s
effect
 therapy.

1. ASSESSMENT

Physical examination
Weight Age
Physical parameters related to
the disease state or known
drug effects

Physical Parameters Related

to Disease or Drug Effects
The specific parameters that
need to be assessed depend
on the disease process being
treated and on the expected
therapeutic and adverse effects
of the drug therapy. Assessing
these factors before drug
therapy begins provides a
baseline level to which future
assessments can be compared
to determine the effects of drug
 continuatio n

Physical Examination
to determine if any conditions exist that may have
an adverse reaction to drug use
Weight
helps to determine whether the recommended
drug dose is appropriate.
Because the recommended dose typically is
based on a 150-pound adult man, patients who
are much lighter or much heavier
often need a dose adjustment.
Age
Patients at the extremes of the age spectrum
—children and older adults—often
require dose adjustments based on the functional
level of the liver and kidneys
and the responsiveness of other organs
 A nursing diagnosis is simply a statement of
the patient’s status from a nursing perspective

When applied to pharmacotherapy, the diagnosis

phase of the nursing process addresses three main
areas of
concern:
● Promoting therapeutic drug effects.
● Minimizing adverse drug effects and toxicity.
● Maximizing the ability of the patient for
self-care, including the knowledge, skills, and
resources necessary for safe and effective drug
administration.

Nursing diagnoses that focus on drug administration may address actual

problems, such as the treatment of pain; focus on potential problems, such as
a risk for deficient fluid volume; or concentrate on maintaining the patient’s
current level of
wellness.

Two of the most common nursing diagnoses for medication administration are
Deficient Knowledge and Noncompliance.
B. PLANNING
• The planning phase of the nursing process prioritizes
diagnoses, formulates desired outcomes, and selects nursing
interventions that can assist the patient to establish an
optimum level of wellness

• Short- or long-term goals are established that focus on what

the patient will be able to do or achieve, not what the nurse
will do
• With respect to pharmacotherapy, the planning phase
involves two main components:
1. drug administration and
2. patient teaching.

The overall goal of the nursing plan of care is the safe and
effective administration of medication.
To achieve this, the nurse focuses on safe medication
administration and monitoring of the patient’s condition and
planning for patient teaching needs related to the drugs
prescribed.
 C.
INTERVENTION

1
.

The primary role of the nurse in drug

administration is to ensure that prescribed
medications are delivered in a
safe manner
RESPONSIBILITIES OF THE NURSE IN DRUG
ADMINISTRATION
Whether administering drugs or supervising the use of drugs by their
patients, nurses are expected to understand the pharmacotherapeutic
principles for all medications The nurse’s responsibilities include
knowledge and understanding of the following:
● What drug is ordered.
● Name (generic and trade) and drug classification.
● Intended or proposed use.
● Effects on the body.
● Contraindications.
● Special considerations (e.g., how age, weight, body fat
distribution, and individual pathophysiological states affect
pharmacotherapeutic response).
● Side effects.
● Why the medication has been prescribed for this particular patient.
● How the medication is supplied by the pharmacy.
● How the medication is to be administered, including dosage ranges.
● What nursing process considerations related to
the medication apply to this patient.
 The professional nurse can routinely avoid many
serious adverse drug effects in patients by
applying experience and knowledge of
pharmacotherapeutics to clinical practice. Some
adverse effects, however, are not preventable. It
is vital that the nurse be prepared to recognize
and respond to potential adverse effects of
medications.
An allergic reaction is an acquired hyper response
of body defenses to a foreign substance (allergen).
Signs of allergic reactions vary in severity and
include skin rash with or without itching, edema,
runny nose, or reddened eyes with tearing

Anaphylaxis is a severe type of allergic reaction that involves the massive,

systemic release of histamine and other chemical mediators of
inflammation that can lead to life threatening shock
 4.
IMPLEMENTATION/INTERVENTION
The implementation phase is when the nurse applies the
knowledge, skills, and principles of nursing care to help
move the patient toward the desired goal and optimal
wellness.
Implementation (in general) involves action on the part of
the nurse or patient: administering a drug, providing
patient teaching and initiating other specific actions
identified by the plan of care.
What are the responsibilities of the nurse prior
administration ?
When applied to pharmacotherapy, the implementation
phase involves
1. ROUTES /administering the medication,
2. continuing to assess the patient = WHO
3. and monitoring drug effects, = WHO
4. carrying out the interventions developed in the planning
phase to maximize the therapeutic response and prevent
adverse events,
5. and providing patient education to ensure safe and
effective home use of the medications.
 ROUTES OF DRUG ADMINISTRATION Nurse Responsibility
Prior adm.
The three broad categories of routes of drug administration as the
implementation phase in pharma are :
1. Enteral
2. Topical
3. parenteral
1. Enteral Drug Administration

The enteral route includes drugs given orally and those administered through
nasogastric or gastrostomy tubes ( buccal = bet. Cheek & the gum). Oral 1 hr
before and 2 hrs after meals
• Oral drug administration is the most common, most convenient, and
usually the least costly of all routes.
• safest route because the skin barrier is not compromised.
• In cases of overdose, medications remaining in the stomach can be
retrieved by inducing vomiting.
• Oral preparations are available in tablet, capsule, and liquid forms.
• Medications administered by the enteral route take advantage of the vast
absorptive surfaces of the oral mucosa, stomach, or small intestine. The
enteric coated tabs are designed to dissolve in the alkaline
environment of the small intestine.
Nasogastric & Gastrostomy Drug Administration

A nasogastric (NG) tube is a soft, flexible tube

inserted by way of the nasopharynx with the tip lying
in the stomach. A gastrostomy (G) tube is surgically
placed directly into the patient’s
stomach. Generally, the NG tube is used for
short-term treatment, whereas the G tube is inserted
for patients requiring long-term care.
 2. Topical Drug
Administration
Topical drugs are those applied locally to the skin or the
membranous linings of the eye, ear, nose, respiratory tract,
urinary tract, vagina, and rectum.

Transdermal Delivery System

The use of transdermal patches
provides an effective means of
delivering certain medications.
Examples include nitroglycerin
for angina pectoris &
scopolamine (Transderm-
Scop) for motion sickness

Drugs to be administered by this route

avoid the first-pass effect in the liver
and bypass digestive enzymes
 Ophthalmic
Administration
The ophthalmic route is used to treat
local conditions of the eye and
surrounding structures. Common
indications include excessive dryness,
infections, glaucoma, and dilation of the
pupil during eye examinations.
Ophthalmic drugs are available in the
form of eye irrigations, drops, ointments,
and medicated disks.

Otic
Administration
The otic route is used to treat local
conditions of the ear, including infections
and soft blockages of the auditory canal.
Otic medications include eardrops and
irrigations, which are usually ordered for
cleaning purposes.
 Nasal
Administration
The nasal route is used for both local
and systemic drug administration. The
nasal mucosa provides an excellent
absorptive surface for certain
medications. Advantages of this route
include ease of use and avoidance of the
first-pass effect and digestive enzymes.

Vaginal
Administration
The vaginal route is used to deliver
medications for treating local
infections and to relieve vaginal pain
and itching.
Vaginal medications are inserted as
suppositories, creams, jellies, or
foams.
 Rectal
Administration
It is a safe and effective means of
delivering drugs to patients who are
comatose or who are experiencing nausea
and vomiting. Also, the appropriate
alimentary route when passage through
the liver is lessen.

3. Parenteral Drug
Administration
Parenteral administration refers to the
dispensing of medications by routes other
than oral or topical. The parenteral route
delivers drugs via a needle into the skin
layers, subcutaneous tissue, muscles, or
veins.
 3.1 Intradermal Administration

Injection into the skin delivers

drugs to the blood vessels that
supply the various layers of
the skin. Drugs may be
injected either intradermal or
subcutaneously. The major
difference between these
methods is the depth of
injection

ID injection is usually employed for allergy and disease screening or

for local anesthetic delivery. The usual sites for ID injections are the
nonhairy skin surfaces of the upper back, over the scapulae, the high
upper chest, and the inner forearm
 3.2 Subcutaneous Administration

A subcutaneous injection is delivered

to the deepest layers of the skin. Body
sites that are ideal for subcutaneous
injections include
the following:
● Outer aspect of the upper arms, in
the area above the triceps muscle.
● Middle two thirds of the
anterior thigh area.
● Subscapular areas of the
upper back.
● Upper dorsogluteal and
ventrogluteal areas.
● Abdominal areas, above the iliac
crest and below the diaphragm, 1.5 to
2 inches out from the umbilicus.
 3.3 Intramuscular Administration

An intramuscular (IM) injection delivers

medication into specific muscles.
Because muscle tissue has a rich blood
supply, medication moves quickly into
blood vessels to produce a more rapid
onset of action than with oral, ID, or
subcutaneous administration. Injection
sites must be located away from bone,
large blood vessels, and nerves
The four common sites for intramuscular injections are as follows:
1. Ventrogluteal site. The preferred site for IM injections. Provides
the greatest thickness of gluteal muscles, contains no large blood vessels
or nerves, is sealed off by bone, and contains less fat than the buttock
area, thus eliminating the need to determine the depth of subcutaneous
fat. It is a suitable sitefor children and infants over 7 months of age.
2. Deltoid site. This site is used in
well-developed teens and adults for
volumes of medication not to exceed
1 mL. because the radial nerve lies
in close proximity

3. Dorsogluteal site. This site is

used for adults and for children who
have been walking for at least 6
months. The site is rarely used due
to the potential for damage to the
sciatic nerve.
4. Vastus lateralis site. The
vastus lateralis is usually thick and
well developed in both adults and
children. The middle third of the
muscle is the site for IM injections.

HOW ABOUT THE ABDOMEN?

3.4 Intravenous Administration Intravenous (IV) medications and
fluids are administered directly into
the bloodstream and are
immediately available for use by
the body. The IV route is used
when a very rapid onset of action is
desired. As with other parenteral
routes, IV medications bypass the
enzymatic process of the digestive
system and the first-pass effect of
the liver
The three basic types of IV administration
are as follows:
1. Large-volume infusion. This type
of IV administration is for fluid
maintenance, replacement, or
supplementation. Compatible drugs may
be mixed into a large- volume IV
container with fluids such as normal saline
or Ringer’s lactate.
2. Intermittent infusion. This is a
small amount of IV solution that is
arranged in tandem with or piggybacked
to the primary large-volume infusion.
It is used to instill adjunct medications,
such as antibiotics or analgesics, over a
short time period.

3. IV bolus (push) administration.

This is a concentrated dose
delivered directly to the circulation
via syringe to administer single-dose
medications. Bolus injections may be
given through an intermittent injection
port or
by direct IV push.

Effectiveness of IV meds is
monitored 10-15 minutes after
administration.
 2. MEDICATION ORDER

A medication order is written directions provided by a

prescribing practitioner for a specific medication to be
administered to an individual. The prescribing practitioner
may also give a medication order verbally to a licensed person
such as a pharmacist or a nurse.

Examples of some different types of medication orders are:

• Copy of a written prescription
• Written order on a consultation form, signed by the practitioner
• Written list of medication orders, signed by the practitioner
• Copy of a pharmacy call-in order, given to you by the pharmacist*
• A verbal order given to a licensed person*
• Electronic prescriptions signed electronically via a secured system
 MEDICATION ORDERS

• A STAT order refers to any medication that is needed immediately and

is to be given only once. It is often associated with emergency
medications that are needed for life- threatening situations.
• The term STAT comes from statim, the Latin word
meaning “immediately.”
• The health care provider normally notifies the nurse of any STAT order
so it can be obtained from the pharmacy and administered immediately.
• The time between writing the order and administering the drug should
be 5 minutes or less

• ASAP order (as soon as possible) should be available for administration

to the patient within 30 minutes of the written order.

• HOW DO WE IDENTIFY THE PATIENT ?

• The single order is for a drug that is to be given only once,
and at a specific time, such as a preoperative order.

• Standing order – protocols derived from guidelines created by

health care 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

• PRN medication orders are given on an "as needed"

basis for specific signs & symptoms