Pharmacology and the Nursing Process in LPN Practice
Objectives
1. List how LPNs are involved in the five steps of the nursing process.
2. Identify subjective and objective data.
3. Discuss how LPNs use the nursing process in administering medications.
Key Terms
assessment (ă-SĔS-mĕnt, p. 2)
auscultation (ăw-skŭl-TĀ-shŭn, p. 3)
database (DĀT-ă-bās, p. 2)
diagnosis (dĭ-ăg-NŌ-sĭs, p. 4)
evaluation (ĭ-văl-ū-Ā-shŭn, p. 7)
implementation (ĭm-plĕ-mĕnTĀ-shŭn, p. 5)
inspection (ĭn-SPĔK-shŭn, p. 3)
nursing process (NŬR-sĭng PRŎ-sĕs, p. 1)
objective data (ŏb-JĔK-tĭv DĀT-ă, p. 3)
palpation (păl-PĀ-shŭn, p. 3)
percussion (pĕr-KŬ-shŭn, p. 3)
six “rights” of medication administration (mĕd-ĭ-KĀ-shŭn ăd-mĭn-ĭ-STRĀ-shŭn, p. 5)
subjective data (sŭb-JĔK-tĭv DĀT-ă, p. 3)
therapeutic effects (thĕr-ă-PŬ-tĭk, p. 8)
The LPN’s Tasks and the Nursing Process
http://evolve.elsevier.com/Edmunds/LPN/
Licensed Practical or Vocational Nurses (LPNs/LVNs) play an important role in giving nursing care, and their responsibilities are predicted to grow. There are many factors that will increase the future demand for nurses: many more people are retiring, older people are living longer, chronic diseases are affecting more people, and the incidence of problems like obesity and dementia are increasing. At the same time, more registered nurses (RNs) are retiring and leaving the workforce and fewer RNs are being trained to replace them.
The LPNs/LVNs of the future will have more responsibility in this changed environment. More tasks of the RN will be delegated to the LPN/LVN. There will be a growing need for LPNs/LVNs in most places where health care is being offered. The patients in today’s hospitals are often very ill and require close attention. There may be many new types of technicians and technology to dispense unit-dose medications in large city hospitals, but in nursing homes or small community hospitals, there may be few nurses and little equipment. Nurses may copy medications orders from a patient’s chart and carry the medicine in paper souffle cups to the patient. LPN/LVNs will be increasingly employed in these areas. Caregivers and patients may come from different cultural backgrounds, and there may be co-workers from several different cultures. All these changes in the health care workplace may lead to stress, cultural conflicts, misinterpretation, or confusion unless these factors are recognized and addressed.
Although most LPNs/LVNs are familiar with the nursing process, it is likely there will be fewer RNs in the future, and LPNs/LVNs should understand clearly how to proceed in an organized way as they plan care for patients. LPNs/LVNs will find work in some of the most technically complex and challenging aspects of health care, as well as working in facilities both in the United States and abroad, where they may be the health care leader and there are no fancy machines, testing equipment, or treatment plans. LPNs/LVNs will learn to use the latest equipment to provide care or to calculate drug dosages with a paper and pencil.
Nursing care is often complex. Nursing actions are specific behaviors that are carefully planned. The well-known process that helps guide the nurse’s work in logical steps is known as the nursing process. The nursing process consists of the following five major steps:
All of these steps are followed when you are giving medications to patients. The nursing process is shown in Figure 1-1.
RNs have both the knowledge and the authority they need to carry out all the steps of the nursing process. Their nursing actions do not require a legal order, so the RNs are acting independently. LPNs/LVNs do not have the same type of authority when they work with patients. Although LPNs/LVNs may need to rely on the RNs they work with in the planning and evaluation steps of the nursing process, they may be more independent as they collect data (assessment step) or help with the care of the patient (implementation step). For example, RNs interview the patient and do a physical examination of the patient, while LPNs/LVNs also learn information as they work with patients. It is usually the LPN/LVN who takes vital signs, checks response to medications and treatments, and monitors symptoms the patient is having. RNs and LPNs/LVNs work together to carry out medication or treatment orders written by health care providers. (Physicians are not the only ones who write orders. You may work with nurse practitioners, physician assistants, or other types of health care providers who may legally write orders.)
As you grow in the LPN/LVN role and gain experience, you will learn more complex skills that help with the nursing process. LPNs/LVNs are often given greater responsibility as they show they can do the work. In nursing homes and extended-care facilities, you may have opportunities to be a charge nurse and to manage patient care under the supervision of the RN. So it is important to master all parts of the nursing process. Experienced LPNs/LVNs will also assume more responsibility if no RN is directly available.
Assessment
An RN is legally assigned as the staff member who must perform the initial assessment for each patient. However, the LPN/LVN is often asked to assist with this task.
Assessment involves looking and listening carefully. It is a process that helps you get information about the patient, the patient’s problem, and anything that may influence the choice of drug to be given to the patient. This step of the nursing process is important because it gives you initial information as you begin to make a database, or record, from which all other nursing-process plans grow. Assessment means getting information by talking to the patient, looking at old records, or reviewing materials that the patient may bring. When the patient is admitted to the hospital, ask carefully about any current health problems, as well as any history of illnesses, surgery, and medications taken both now and in the past. This information is important for all team members to know and helps everyone plan the patient’s care. Information in the patient’s history often directs the nurse and the physician to look for certain physical signs of illness that may be present.
Information you gather through assessment falls into two groups: subjective data and objective data. Subjective data, or information given by the patient or family, includes the concerns or symptoms felt by the patient. Examples of subjective data include:
• The chief problem of the patient (in the patient’s own words)
• The detailed history of the present illness
• The medical history of the patient
• Social information: the patient’s job, education level, and cultural background
Some patient problems are more subjective than others. For example, if a patient reports pain in the abdomen, you must accept the patient’s word that the pain is present. The nurse cannot see, hear, or feel the patient’s abdominal pain—that is why it is subjective. A patient may state that he or she has trouble breathing. Although you may observe rapid breathing, the degree of difficulty cannot be measured. Information is subjective if you have to rely on the patient’s words or if the symptoms cannot be felt by anyone other than the patient. In such cases, you would report, “The patient states that. . . .”
Objective data is obtained when the health care provider gives the patient a physical examination. It also comes from documents that patients bring with them, such as old laboratory results, electrocardiogram (ECG) printouts, or x-rays, and from information you gather during the physical examination. Patients may even bring their medicines with them to the hospital or clinic. Objective data are gathered through assessment of vital signs (respiratory rate, pulse, blood pressure, weight, height, temperature); physical findings you can see during careful inspection (close observation), palpation (feeling), percussion (feeling differences in vibrations through the skin), and auscultation (listening with the stethoscope); and the results of recent laboratory tests and diagnostic procedures.
It is especially important to get subjective and objective assessment data when the patient is first seen or on admission to the hospital. This provides initial, or baseline, information that can be used to determine how ill the patient may be. Assessment is then done throughout the period of care to see if the patient is getting better with the treatment ordered.
The nurse may not always be the one gathering the subjective and objective data; however, the nurse and everyone else on the health care team should learn whatever information they can from the chart, the physician, the family, or other team members, and use that information to plan the patient’s care. Understanding the difference between subjective and objective information will help you in reporting, or charting, the information. For example, if the patient reports pain (subjective information), your notes should say, “The patient complains of pain” rather than “The patient has pain,” because you do not know if what the patient is feeling is actually pain or only discomfort. Much of your job in assessing will be reporting data you collect to the RN. As you learn more skills, or work in places such as nursing homes where you may have more responsibility, you will play a larger role in assessing the patient. How big a part you play in assessing the patient is defined by your state nurse practice act, which lists what LPNs/LVNs may and may not do.
Factors to Consider in Assessing the Patient
Certain information is very helpful in planning drug therapy. The nursing assessment at the time of the patient’s admission to the hospital should take special note of the drug history. You must talk to the patient, who is the first or primary source, but sometimes you also have to talk to a patient’s relatives or get old medical records, ECG results, or laboratory reports (secondary sources). Sometimes your nursing books or the Internet (tertiary sources) may also provide helpful information about a specific disease, medication, or procedure.
When asking about the patient’s drug history, the nurse makes assessments in the following areas:
2. Current (and sometimes past) use of all medications and drugs:
• All prescription medications (patients often forget to mention birth control pills in this category)
• Alcohol or street drugs used for recreational purposes (such as marijuana or cocaine)
• Alternative therapies such as herbal medicines or aromatherapy
You will also be assessing changes in patient condition or status that may influence drug therapy during the time the patient is in the hospital. This is how you will know if the medication is helping the patient or not.
Memory Jogger
Nursing Assessment
Assessment means learning as much as you can about your patients and their problems.
Diagnosis
Once the assessment information has been collected, the LPN/LVN and other health care team members must make a diagnosis (a conclusion about the patient’s problem). The physician will decide the medical diagnoses. The RN will identify the nursing diagnoses. The hospital where you work may use the formal nursing diagnosis system developed by the North American Nursing Diagnosis Association–International that allows RNs to share a common language and a common way of describing a patient’s condition. However, many hospitals do not recognize or use this system. In either case, after talking to the patient, you will come to some decisions about how sick the patient is and how carefully you need to watch them. You will make your own decisions about some of the following questions:
• What procedures or medications will this patient require?
• What special knowledge or equipment is required in giving these medications?
