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.

Factors to Think About in Planning to Give a Medication

The Right Drug

Many drug names are hard to remember and difficult to read. Also, many drugs have names that sound or look nearly the same as the names of other drugs. It is important to carefully check the spelling of the name and the dose of each medication before any drug is given. For example, NovoLog and Novolin are both insulin products used for diabetics, but they are quite different in dosage and duration of action. It is also easy to get confused when a medication is ordered by a trade name (such as Valium), but the pharmacy sends up the medication labeled with the generic name (diazepam). Do not assume that the correct medication has been sent without checking a reliable source or calling the pharmacy.

The Right Time

The Right Dose

The amount of medicine to be given is usually ordered for the “average” patient. A patient who is old, who has severe weight loss as a result of illness, or who is small or very obese may require changes in the usual dosages. Pediatric patients have doses ordered depending on how much they weigh. Geriatric, or older adult, patients may be very sensitive to many medications and may require a change in dosage. If patients have other diseases or poor liver or kidney function, this may make changes in dosage necessary. Patients who have nausea or vomiting may be unable to take oral medications. Also, the physician may order the correct dosage of the medication when treatment begins, but changes in the patient’s condition may require that you go back to the physician to have the dose altered.

Giving the correct dosage of a medication also requires that you use the proper equipment (for example, insulin must be measured in an insulin syringe), the proper drug form (oral or rectal, water or oil base, scored tablets or coated capsules), and the proper concentration (0.25 mg or 2.5 mg) and that you accurately calculate the right drug dosage. Most hospitals and clinics have rules that require two nurses to check any medication dosage that must be calculated, particularly for medications such as narcotics, heparin, insulin, or IV medications.

The Right Patient

Typically, hospital procedure requires that we ask the patient for their name and birth date and also confirm their identify by examining the wrist band. Although it seems like common sense to make certain the right patient gets the medication, errors may occur on a busy hospital unit. Several groups of patients are most at risk for errors: the pediatric patient, the geriatric patient, the non–English-speaking patient, and the very confused or critically ill patient. The common factor among these four groups is that it might be hard for them to tell the nurse who they are. They also may not understand what you are asking or that a drug is being given to them. The identification bracelets (name bands) that some patients wear may have been removed for tests or when blood was drawn. Be especially careful with children, because they enjoy hiding, changing beds, answering to another name, and so on. Ask for the name as you check the patient’s identification bracelet or scan their name tag to confirm it is the correct patient. In a hospital, medications should never be given to a patient who is not wearing an identification bracelet. Nursing homes may present a special challenge for a nurse who does not know the patients well, because these patients may not wear identification bracelets, and they may be confused or unable to answer to their name. When available, the use of computers to scan the patient’s identification bracelet and the drug itself are helpful in making sure the correct patient gets the drug.

The Right Route

The drug order should state how the drug should be given (route of drug administration). The nurse must never change routes without getting a new order. Although many drugs may be given by different routes, the dose is often different for each route.

The oral route is the preferred route if the patient is oriented (awake and able to understand). In some cases, faster delivery or a higher blood level of a drug is needed, so the medication may be given intravenously or intramuscularly. There may be special precautions for medications given through these routes (such as how fast they can be given or in what dosage). Some injections should be given into the subcutaneous tissue rather than intramuscularly. Because of these differences, you need to know how to give an injection in several different places on the body. Also, some drugs are very painful if given intramuscularly, so giving them intravenously is preferable.

When drugs to help breathing are ordered, you need to find out whether the aerosol nebulizer is to be used through the nose or the mouth. Teach the patient the correct way to use the nebulizer so that the medication goes all the way into the lungs. Teach patients how to correctly use their eye drops, eardrops, ointments, lotions, shampoos, and rectal or vaginal medications.

The Right Documentation (Record Keeping)

Increasingly, electronic charting systems are being introduced into medical settings. Whether the nurse records medication administration and patient observations by hand or using an electronic chart, the basics are the same. A note about how and when you gave the drug should be made on the patient’s chart as soon as possible after the drug is given. In an emergency or when a drug is only used once or twice, this is very important. Rules at your agency may require that the chart note of intramuscular medications also include where on the body you gave the injection and any complaints made by the patient at the time of the injection. The chart note should always list the drug given, the dose, and the time it was actually given (not the time it was supposed to be given). In some offices or clinics where immunizations are given, the policy may require that the lot number listed on the bottle be recorded in the patient’s chart. Progress notes should include a note about the patient’s response to the medication. Any complaints or adverse effects should be noted in the chart and reported to the head nurse and the physician. When you make notes in the patient’s chart about medications, never record medications that were not given or record them before they are given. If a patient does not receive the medication, for any reason, notify the nurse in charge or the person who wrote the order.

It must be stressed that you must never give medication prepared by another nurse. Even when you are very busy, when there is an emergency, or when you are interrupted, you cannot assume that all the “rights” are followed unless the person who prepares the medication is the one who gives the medication. Sometimes a physician will ask you to prepare the medication for the physician to give. You may then prepare the medication, but go with the physician to see that the medication is given as ordered and write in the notes that the physician gave the medication.

Following the rules of your hospital, using common sense, and being accurate and ethical will reduce the risk of medication error. Should an error be made, talking about it honestly and taking quick action to correct any damage are especially important to protect the patient from harm.

Factors to Think About in Evaluating Response to Medication

The nurse checks for two types of responses to drug therapy: therapeutic effects and adverse effects.

Therapeutic effects are seen when the drug does what it was supposed to do. If you understand why the medication is being given (the therapeutic goal of the drug), you will be able to decide whether or not that goal is being met. For example, if the patient’s blood glucose is high and regular insulin is given, you should see a lower blood glucose level when the test is repeated in 1 to 2 hours.

Adverse or side effects are seen when patients do not respond to their medications in the way they should or develop new signs or symptoms. For example, a patient with pneumonia may be given penicillin. Although this antibiotic may be working to control the infection, the patient may develop shortness of breath, which may be an allergic reaction to the medicine, and the penicillin must be stopped. A patient getting an anticoagulant to thin the blood must be closely watched for signs of bleeding or bruising that would indicate overdosage or overresponse to the medication. Sometimes, side effects such as nausea or vomiting may be stopped by decreasing the dosage or by giving the medication with food. Telling the physician about whether the side effects are mild or severe helps the physician decide whether the patient should keep taking the drug or it should be stopped.

The nurse is the health care worker most often with the patient and is in an important position to notice the patient’s response to drug therapy. Carefully and repeatedly evaluating the patient and writing down the findings in the patient’s chart are especially important in the care of the hospitalized patient.