Chapter One: Pharmacology in the Nursing Process

we're beginning with chapter one pharmacology in the nursing process in LPN practice LPNs an important role in giving nursing care providing care to their patients and the responsibilities of the LPN slash LVN are really predicted to grow because more and more excuse me RNs are leaving the workforce and they're not necessarily replacing them with other RNs so LPNs are being um hired in those roles now more tasks of the RN will be delegated to the LPN slash LVN LVN is just a licensed vocational nurse they really pretty much mean the same thing and so delegation is when one person is assigning a task to another person now just be sure you understand and I'll mention this again the person who delegates is still responsible to make sure that whatever was delegated gets done it's part of accountability LPNs and LVN should understand clearly how to proceed in an organized way as they plan care for patients and then um obviously because the roles and responsibilities are going to be changing the LPN obviously needs to learn how to use the latest equipment um you know and whatever they may be having to be involved with so the lpn's responsibilities are as I said continually changing so it's very important to know what the nurse Practice Act says in your state every state has its own nurse Practice Act now notice that the slide says the RN licensure and authority to carry out all steps of the nursing process this differs from the LPN the LPN Works under the supervision of the RN to assess Implement and evaluate with guidance now we're going to talk about the nursing process in just a second but it has five pieces assessment diagnosis planning implementation and evaluation and you'll notice here that it does not state that the LPN is involved in diagnosis and planning but with that said it just means that the LPN doesn't do the initial assessment the LPN cannot formulate the diagnosis even though the LPN provides information and supports the formation of that diagnosis and the same thing is true of the initial planning the RN has to write out the plan for the patient's care but the LPN contributes tremendously to all of these steps LPNs practice in nursing homes Assisted Living agencies outpatients clinics Home Health agencies hospices rehabs LPN is involved in Drug Administration they have a very significant role as if many of you know in many facilities it's the LPN who's carrying out that particular role so as I said there are five steps to the nursing process the nursing process is literally a framework for how the nursing profession practices it's a scientific standardized process that ensures quality patient care it assists the nurse in meeting the standards of care for the patients I mentioned accountability before and so I want to mention it again the nursing process facilitates a nurse's accountability for his or her practice if you're following the steps of the nursing process in order as you should it helps the nurse be accountable for what they are doing now here I'm just showing you two ways to look at the nursing process add pie is the most common adpie assessment diagnosis planning implementation and evaluation you will find some literature that leaves out the word diagnosis and says analysis instead so instead of add pie we can use a little acronym and apple pie assessment analysis planning implementation and evaluation if you think about it when you do an assessment what do you do with that information you check your patients vitals you listen to their lungs you know you do all those things then what do you do write it down and walk away well don't you analyze that data what does it mean right is this an abnormal pulse is this you know abnormal heart sounds so you're analyzing the assessment data and with that you formulate in your mind what you think is the patient's potential problem that's a nursing diagnosis okay so they really mean the same thing it's just different words all right so I already mentioned what it is it's a framework for professional practice it guides nurses how we think how we act it's scientific it's standardized and I want to point out to you that the steps do need to be completed in order you can't Implement care before you assess your patient it doesn't make sense to say oh I'm going to go give my patient Tylenol for their temperature but I haven't even taken their temperature you see what I'm saying you assess then you carry out your your plan of care it does facilitate that nurse's accountability for their practices I said and so my next question is so what is the licensed practical nurses part responsibility whatever in the nursing process this is a diagram from your textbook and it's just showing you the various steps now you notice that we start with a big blue circle on the upper right assessment we're going to get objective and subjective data from that collection of information we're going to formulate a diagnosis or determine what our patient's problems are we're going to plan their care carry out the care and in this situation we're talking about giving meds so you'll see the nine rights of drug safe medication administration and then we evaluate we're looking for therapeutic effects and we're looking for adverse effects and so forth so again this is just showing you the picture that is in your textbook to help you understand the steps of the nursing process so assessment now I have given you um those of you that are watching this for class you were given uh what I call a packet of information we're giving I'm giving you pieces each week as we go over new content and it's your note taking tool some of you may have this some of you may not but if you do have that packet I want to indicate for you that anything that is in red and underlined would be blanks in your packet so as you're taking notes you can fill in the blanks with this information so as I said assessment we're gathering information we get it by talking to our patient looking at them closely observing them getting signs and symptoms looking at old records reviewing material a patient may bring it's our database okay so with our database it does include the physical assessment of the patient's history so notice here we say the RN is legally assigned as the staff member who must perform the initial assessment for each patient so the RN has to get the initial assessment okay after that then the LPN can be assessing but initially it has to be an RN it involves looking listening carefully asking questions it's a process that helps you get information about the patient the patient's problems anything that may influence the choice of drug to be given to the patient so once again if we're going to get the physical assessment our patient's history review Systems and so forth there are two types of data that we talked about that we're going to collect subjective and objective and I know on your ticket to class one of the questions that you had was to differentiate between these two and give an example subjective data it's what the patient says so it's obtained through questioning information that can't be measured I ask my patient how their pain is I can't measure that they have to tell me okay if my patient feels like their heart is pounding in their chest I can measure their pulse but I cannot measure palpitations that is a sensation the patient experiences so it is subjective objective data on the other hand is what I can get through observation information that I can verify that I can measure another person I can get it on the physical exam I can obtain Vital Signs lab results because anybody who looks at that will come to the same conclusion in other words when I'm checking the skin it's warm it's dry okay if I'm attaining vital signs I have numbers to look at lab results numbers to look at so subject is what the patient says objective is what we can observe and that can be measured so where do we get our information well the main source obviously is our patient or the client right but sometimes that person maybe has Alzheimer's or it's a child or somebody who can't give us information so it might be the family member medical records are another source of information patient being the primary but medical records you can look at old charts old records obtain your patients history get information from other health care providers sometimes they have consult sometimes they have multiple problems where they're seeing many Physicians so data from those positions and then of course we've already discussed the fact that lab results can also give us some of that information so when we are getting our objective data the previous slide was about our history okay patient telling us things family telling us things and so forth but our objective data is through the physical exam inspections the first part of the physical exam just looking at your patient observing them you can observe when you see a patient who is in distress you know they're breathing really rapidly you can see a patient who is clutching their incision area somebody with their hand over their head you know what I'm saying you're looking observing but inspection is also General appearance things like that palpation now don't confuse this with palpitation that's a term I used in the previous slide about feeling your heart beating in your chest palpation is the is the act of feeling touching you know checking pulses you're actually palpating a pulse feeling um internal organs checking for edema in the ankles you're actually touching the skin you're palpating to feel for that swelling percussion detecting differences in vibrations through the skin this is not used much at all anymore but it is still used in some places and it's typically done by the RN not the LPN but let me give you an example of percussion you may not have ever heard this term before but we have what is called CVA tenderness costovertebral angle tenderness it's actually a sensation the person has when they have kidney problems and when you put your hand over the cost overtebral angle it's sort of on the rib cage on the side where people think their kidneys are located and then you put your hand there and I'll show you this in class and then you with your other hand you tap your hand over the patient's back and the vibration goes through there tissues and if their kidneys are inflamed it hurts if their kidneys are not inflamed they don't feel a sensation there okay auscultation listening with the stethoscope auscultation so factors to consider in assessing your patient okay so helpful information obtained for the drug history we need to get some information okay so current sometimes they're past use of drugs names dosages as well as over-the-counter meds that's OTC and just keep in mind just a little FYI many patients don't know why they're taking certain medications like they say I take this pill every day but I don't know what it's for okay so an understanding of the patient's current concurrent disease process is also going to be very helpful and what questions could you ask to determine whether patient understands the drug he or she is actually taking what kind of questions could you ask you know the person okay but we want to ask about what are they taking over the counter prescriptions what about alcohol and street drug use that's going to be important because they interact with many medications any alternative therapies herbals dietary supplements and so forth now if you were to say to my husband do you take any medications he would say to you no and he doesn't he doesn't take any medications but he takes a ton of herbals and dietary supplements a ton I'm like I'm saying close to 50. so you have to ask the question now let me say this to you what do you think is the number one reason we need to know if somebody's taking alternative therapies what would be the number one reason again I'm just letting you think this through okay the biggest reason is because they interact with medications okay so if I have a patient who's on a blood thinner and they're taking certain herbal things they could interact and make the blood even thinner and the patient wouldn't clot when they need to okay they might be on a medication that is used for one thing and they take an uh supplement that actually cancels out the effects of that medication so it's very important to know any herbs the patient is taking so you have to ask have they had any problems with any medications you know ask about them do they have any allergies is there any disease or chronic condition that makes a certain medication specific for them to take or contraindicated for them to take what about signs and symptoms of the disease that they have you know that might explain the need for their medication all of that's important to find out and then growth and development which we'll talk about in chapter three growth and development I have under lifespan considerations because it affects how many of those medications work because if they're young they have immature organs if they're old they might have organs that are deteriorating so we need to know things about growth and development all right so assessment our next phase is diagnosis the diagnosis is a conclusion about what the patient's problems are so a physician makes a medical diagnosis okay the nurse makes a nursing diagnosis please note that the medical diagnosis is not in the scope of the RN or the LPN and then the nursing diagnosis is also not in the scope of the LPN it is an RN's responsibility but the LPN can contribute to it okay so pernanda North American nursing diagnosis Association a nursing diagnosis is a clinical judgment concerning a human response to a health condition or life process so I said to you a little bit earlier that um when We Gather our data that's our assessment and we analyze that data we pretty much are coming to a conclusion all right we're coming to a clue conclusion about our patients response to their medical diagnosis we might have a patient with a hip fracture that's their medical diagnosis but as a result of that they have acute pain that is actually a nursing diagnosis as a result of that hip fracture they have impaired physical Mobility that's a nursing diagnosis a classic one for pharmacology and drug therapy is deficient knowledge related to drug therapy you know they have a new medication and as I mentioned earlier there are many patients who actually don't even know what medications they're taking and why so deficient knowledge right that's why we have to educate them so after assessment the nurse determines the nursing diagnosis as I said the RN makes the nursing diagnosis the LPN contributes information to it some questions to ask for developing a nursing diagnosis or what are the major health related problems for the patient what drugs are the patients taking what are the required what special knowledge or equipment is required to give those drugs what special concerns or cultural beliefs you know does the patient have how much does a patient understand about the medications and stuff that's being prescribed for them and what factors affect the patient's ability to care for themselves our next part of the nursing process is plan assessment diagnosis plan implementation evaluation so again notice in your notes that we have some blank so follow along the nursing diagnosis is made a plan of care is initiated that includes patient and nurse involvement please remember that nurses are Patient Advocates we work on their behalf that's what an advocate does you're working on the behalf of somebody else speaking up for somebody planning of care and establishment of goals is done in collaboration with the RN so what are we planning we're planning two major things we're planning goals and planning nursing orders or care so with our goals they're also referred to as outcomes okay they need to be patient centered a goal should never be something the nurse will do this it's the patient will okay so these could be short-term goals like we say as outcome statements so they can be a long-term goal that we want to see accomplished by discharge nursing orders our plan of action is going to help the nurse right their care plan help the client meet the goal okay so there are going to be specific orders for administrative administering medications that's what we're looking at here pharmacology so what are the factors to think about in planning to give a drug well first of all we need to even understand you know what's the reason the drug is given one medication might have four or five indications for example a beta blocker a beta blocker is typically a drug that we think affects the heart it can lower the heart rate it can lower blood pressure it can treat a dysrhythmia of the heart but it's also used for migraine headaches it's used for anxiety it's used to treat hyperthyroidism to slow down the heart so there's a lot of reasons for it wouldn't it make sense to you as a nurse to know why you're giving it because how are you going to know what to assess before you give it and to evaluate its Effectiveness if you don't know the reason they're getting it right learn information regarding the drug including the drug interactions as well as contraindications interactions how does one drug interact with another or even food alcohol and so forth contraindications a reason the patient shouldn't be getting the drug many contraindications could be because the patient has another condition or it could be something like a pregnant female shouldn't take this drug it's contraindicated during pregnancy right does that make sense plan for special storage techniques or equipment you know does it need to be refrigerated does it need can it be used only one time then it has to be disposed of things like that develop a teaching plan the RN is to perform the initial teaching in the LPN reinforces the teaching so what that means is the RN formulates the plan um you know once the RN formulates it of course the LPN can contribute to it but then the LPN can reinforce that teaching to the patient regularly prior to Drug Administration we have to apply critical thinking and so when we're looking at a drug order you know we have to verify first of all is this clear is it appropriate so what do we do what do we do if we question an order so prior to giving the drug verify the accuracy of the drug by checking the medication administration record we call this the mar it's the place where the drug order has been written it's usually copied from a doctor's order or if you work in a facility that has electronic medical records we call this the Emar it could be again you're checking against the provider's order determine whether the type of drug and dosages are appropriate for the patient you have to know this do not second guess or say to yourself well the doctor ordered it it must be okay no you verify if you have any questions so again critical thinking is essential you need to know and follow the nine rights what do you do if you question a drug order don't rely on information from your peers you are responsible for administering the drug know when to question an order and for what reasons and I'm going to address that in just a second but I'm telling you this is part of your responsibility as the nurse so you are looking at an order and you say that's not really clear oh it doesn't look like that's written correctly I've never heard that dosage be that high before or you say the patient's condition would get worse if I gave him this drug their heart rate is already low if I give them this it's going to get even lower right The Physician didn't have all the relevant information needed before writing the order maybe there's some new information that has come about that the doctor didn't have and so he wrote this drug order and you're concerned about giving the medication maybe there's a change in your patient's condition any of those things these are all just examples of what would you do if you're questioning anything first off you do not give the drug the drug is withheld not given until the order is clarified and you're going to clarify it with the health care provider I want to emphasize this to you when you question order you have to check with a health care provider you're going to notify your charge nurse or your supervisor as well and so you want to know what your facility's policy is when you question an order but I'm telling you as a nurse your responsibility is to question it with the health care provider factors to consider in planning to give a drug what's the drug supposed to do learn information about it okay so if I'm going to give a medication to my patient I need to know its major action what is it supposed to do we call this mechanism of action and I gave you some examples already these are going to lower the heart rate is it going to you know treat anxiety is it going to treat a migraine headache is it going to cause them to have diarrhea like I want to know what is the drug supposed to do side effects that may develop that's normal side effects expected obviously what is the usual dosage what is the route and the frequency frequency how often do they get it you want to know what is normal situations in which the drug should not be given what are contraindications and we talked about that just a moment ago like pregnancy somebody has high blood pressure they shouldn't take certain decongestants because they stimulate the heart many drug interactions um I'm just trying to think about many drug interactions just one second here I apologize for the delay um so once again back to this slide what's it supposed to do learn information about its actions expected side effects when would I not give it and then those drug interactions I mentioned before what things could possibly influence you know one drug given with another drug or given at the same time they might cancel out each other you know you just need to know that foreign also when we're planning we talked about that special equipment you know doesn't need to be shook um do is refrigerated Etc so review all that if there's any special technique like is it an inhaler or a patch or anything that you need to put on because sometimes a patch has to be taken off before the next one comes on and you move it from site to site so the skin doesn't get irritated but stuff like that develop a teaching plan for your patient to include what the patient needs to know about the drug what is its action what are the expected effects they need to know what's supposed to happen they also need to know what things may happen those expected side effects so what do they need to know to take the drug the correct way what do they need to report to the nurse or their provider if there's any problems they need to know those things so you need to teach them those items so assessment diagnosis planning implementation this involves following the care plan that you planned and giving the medicine accurately to the patient it requires the nurse use information learned about each patient and about each drug and then you're going to watch for changes in the patient's condition that may make it unwise to give the drug again don't just assume it's ordered I give it under implementation we have the nine rights and I had you um I had you put these on your ticket to class the nine rights of Drug Administration or the uh giving the right drug um right patient right drug write dose right route right time right reason right documentation right response and right to refuse so let's go over those the right patient it's important that you identify patients correctly using two unique identifiers ID number name date of birth but you're not going to say are you John Doe because a confused patient might answer to anything you need to ask them to State their name and date of birth or whatever your facility is using but have them tell you their name don't say are you compare it to the patient's identification bracelet their wristband make sure they match in a hospital setting you never give a drug to a patient who's not wearing an ID band you need to get them one okay many patients are at risk for misidentification for example those that can't effectively communicate you know P to geriatrics critically ill confused those will have English as a second language so in some some long-term care setting they use a client photo they might have it over the top of the bed and then they might have one in their Mar and that's how they verify their patients but you use what your facility does but I'm telling you for testing purposes name and date of birth two unique identifiers but ask them to State their name and date of birth never identify a patient solely solely that means by itself their room number or their bed number never never okay right drug a wrong drug is a main reason for drug errors I mean we're all familiar with drug errors that we've heard about and so forth people making these major mistakes and I'm just saying it's very very important that you have the right medication verify the drug label with the orders or you're checking your medication record and once you have the order the order gets copied onto the mar that's a medication record so once it's on the medication record the nurse is checking the label on the medication with that medication record drug labels verified three times three times are before taking it from the unit dose card or the Shelf before preparing the prescribed dosage and then before preparing it at the patient's bedside giving it to them you're checking the label one last time because if you pour it into the medicine cup it's too late to check the label you you have to check it before you put in the medicine cup the right time for testing purposes and for the Pensacola area we're going to say um one hour before or one hour after the scheduled time so if medication is ordered for 9 A.M it can be given an hour before which is 8 A.M to an hour after which is 10 a.m so between 8 and 10 would be safe to give a regularly scheduled nine o'clock medication now there are exceptions for example insulin okay we um well you don't necessarily know this yet you're going to learn this there are many types of insulin that must be given within 15 minutes of a meal so I don't have that two hour window an hour before or an hour after it's ordered if it says insulin with breakfast it means insulin with breakfast does that make sense sometimes medication is in order to give 15 minutes prior to X then it has to be given 15 minutes prior to X but I'm just talking about routine scheduled medications an hour before an hour after it's scheduled any special considerations know the action of the drug that's going to affect the time a diuretic which is a water pill I'm going to give that during the early part of the day not at bedtime right they're going to get up all night I have to go to the bathroom a stat and that's a cholesterol lowering drug statins work best between midnight and 5 a.m when cholesterol is being synthesized or manufactured in the body so it's best to give a Statin drug in the evening so it can be working while the body would naturally be producing cholesterol but know your hospital policies and patient routines all of that is part of what makes the timing right but look at the order what does the order say if the order is given a specific time follow it if you question that once again go back and question it with a prescriber right reason you need to know the reason the patient's getting it is I've discussed with you already what is the rationale for the use of this medication and does it even make sense for your patient does it make sense that this patient's getting that medication know your patients know the drugs they're getting okay the right dose considerations include age weight their health status any changes in their health status do you have the proper equipment is it the proper drug form the proper concentration I want to mention to you with form um that a form only matters when it's been ordered a specific way let me so for example the doctor says give such and such a medication po that means by mouth but he doesn't say liquid tablet and terracotta it just says by mouth if it's ordered by mouth it can be any of those forms so it can be a tablet it can be a capsule it can be a liquid but if it's ordered to be a special form like enteric coded or if it's ordered to be a sustained release medication then it has to be in that form so again depends upon whether or not it's ordered in a particular form the proper concentration your accurate dosage calculation which we're going to be doing in class frequently is calculating dosages for practice but always verify and clarify when you are in doubt some facilities actually require double checks by another nurse when calculations are required and it's highly recommended to help prevent error the right route don't assume the route if it's not ordered by a particular route you're going to say well how is this supposed to be given now if it's a medication that's only given one way you know that's another story but otherwise look further out routes alter the effects of a drug can affect the dosage um most drugs are given by the enteral route which is the gastrointestinal route in other words something a person is going to put in their mouth it is the most unreliable route though for absorption because GI tract is highly variable in people things like food in the stomach acidity of the stomach you know all those things can affect absorption nurses can't alter the route of a prescribed medication without a physician's order so if you do have to change a route be sure that you call the prescriber and get that order you can't just do it on your own note that the route and form are not the same thing as I just mentioned to you okay the route is by mouth but the form could be a liquid a capsule a tablet Etc consider for the oral route you know how many different ways um you know differences of medications that can be oral and we just went through all that different forms that can be oral as I said the enteral route is the most unreliable because a lot of factors affect absorption the enteral route involves swallowing and it's the only route affected by the first pass effect now this is number 28 in your list of terms in your packet it's also in your textbook under the terminology Within Chapter One um the first pass effect and what I want to tell you about the first pass effect is the first pass effect means that when a medication is swallowed it has a metabolism in the liver prior to getting out to the rest of the body where a lot of the medication becomes inactive so typically if it has a first pass effect the dosage is going to be higher because you're going to lose some in that initial metabolism by the liver and less of it is going to actually get into the bloodstream okay so typically with a first pass effect higher dose initially because you're going to lose some and the first pass effect only applies to medications that are taken in by mouth that you swallow so sublingual is in the mouth but you're not swallowing it sublingual goes under the tongue notice also that drugs should never be left at the patient's bedside for them to take later right documentation we're going to document on the mar our medication administration record if a patient is receiving PRN medications we're also going to document that in the nurse's notes as well as the patient's response so what that means is if my patient has a headache and they've asked for some Tylenol for their headache I'm going to mark it in the mar when I give them the Tylenol but I'm going to put in the nurse notes the patient had a headache and I'm going to ask them to describe it a scale of 0 to 10 with 0 being no pain 10 being the you know most pain they've ever experienced rate their pain I'm going to document that and then after about an hour when I've given that medication a chance to work I'm going to evaluate its response and then I want to chart that too so but with documentation I'm just stating you don't want to document till you give it you only document what you give you never give a drug that you don't prepare never never if you have a nurse at clinical that says to you here give this medication but you didn't prepare it don't do it if you have a nursing instructor who says to you here give this and they hand it to you but you didn't I'm saying like I already put it in a syringe I'm not saying they hand you something in a package you can still verify that's a correct medication but if you didn't put it in that syringe don't give it and you tell them that you when you go to your clinical orientation you're going to sign something that says you're not going to give a medication you didn't prepare so you have something to back this on um document accurately after the drug is administered remember if it isn't documented it isn't done okay and the patient's right response know what the medication is intended to do because again if it's supposed to lower blood pressure how am I going to know if I don't even know that's the reason that they got it continually evaluate the achievement of desired effect did it lower the blood pressure did it decrease their pain did it increase their urine output in other words what is it given for and then I want to know did it work side effects mantra for adverse effects what is the difference in a side effect and adverse effect we often use the terms interchangeably but they're really not a side effect is something that really is almost expected so let's say for example somebody takes a Benadryl for allergies an expected side effect it causes dry mouth it causes the person to get sleepy right most people know that that is a side effect adverse effects could be something like anaphylaxis where somebody breaks out into a rash their throat starts to swell their blood pressure drops that's really really serious that's an adverse effect okay and then of course we're going to document we want to document what it was supposed to do did it do it and whether any adverse effects or side effects document those as well patients have a right to refuse a drug now this is just based upon the principle of autonomy everybody has a right to manage their own care all right so you talk to the patient first and find out why did they refuse the medication sometimes it's just a lack of understanding about what the drug is going to do you want to educate them first so say why why do you not want this medication and they say oh it makes me feel so blah blah blah or when I take this it upsets my stomach well sometimes we can actually say well let's try taking it with a little bit of food okay even when a medication is supposed to be taken on an empty stomach if it makes them sick to their stomach it is still recommended to give it to them with a snack or a little bit of food so that they will take it because what's better taking it with a little bit of food when it's supposed to be on an empty stomach or them not taking it at all right at least they're getting it if you can give it to them with a snack so find out why educate them maybe it's an antibiotic and the patient says I feel good now I don't need any more of my antibiotic well the correct response is in order for this antibiotic to be effective you have to take it for the full cycle because what happens is the antibiotic is weakening the bacteria but it's not going to destroy it until you have a therapeutic blood level for a significant amount of time and what that does is it makes the bacteria that's causing this infection actually get stronger it produces drug resistance so patients need to understand this if they still refuse you're going to document this in the medical record you're going to notify the prescriber per whatever protocol your facility has so it's very important that you document it and that you notify so my question is this what is the nurse's responsibility when a patient refuses their medication educate and document okay if you educate them they may take the medication but whether they do or they don't document that they refused the reason why they refused that you educated them about the medication that's very important to include in the documentation right education use every opportunity to teach your patients and family about their meds include ways to enhance the drug therapy with diet exercise you know lifestyle changes you know maybe they're taking like I say a Statin drug to lower their cholesterol well what else can help with their cholesterol Believe It or Not exercise helps lower cholesterol educate about what the medication is intended to do what's its purpose because again if they don't know you know they're not even going to understand so educate them about it it's also important to educate about potential side effects so they can be looking for those side effects can be a main reason for non-compliance think about this patient doesn't like the way a medication makes them feel so they stop taking it but if you explain to them the side effects it may help them to be more compliant understanding this is a normal side effect my mouth getting dry is expected I just need to continue taking my medication now if they're on a medication that has a nasty side effect they've been told about it and if that side effect occurs you might say to them notify your prescriber if this becomes uncomfortable for you because they may need to give you a different medication but non-compliance a main reason for that is not liking the side effects of medication and educating the patient will help reduce them being non-compliant our last part of the nursing process is evaluation it's the process of determining the right response looking what happens to the patient when the nursing care plan is put into action it requires you to watch their patient to for that correct response noting both expected and unexpected findings helps the healthcare team decide whether to continue with the same drug or make changes I mean you think about it we're looking at saying did the medication work did it do what it's supposed to do or did it have adverse effects I want to document both my question to you here is what is the difference between assessment and evaluation right so let's stop and think what am I doing when I assess what am I doing when I evaluate okay oh I'm sorry I thought I had the answer on here let me go back I thought I had it right there interestingly I don't have it on that slide so let me just go ahead and say what I was going to say I must not have saved the difference in assessment and evaluation okay they are both assessment both are assessment I assess my patient's blood pressure before I give them their antihypertensive okay I'm writing it down it's 156 over 86 I'm writing it down I give them the medication I allow the medication time to work and now I'm going to go evaluate the effectiveness and what do I do I assess the blood pressure again does that make sense so assessment per se is prior to your nursing intervention evaluation is after the intervention all right now factors think about evaluating a response to drugs it's important for patients to understand the time frame which the therapeutic effects of a drug will occur if I have a medication that's not going to show effects for about two weeks don't you think the patient should know that if you give a medication that's not going to show effects for about an hour they need to know that teaching is essential patients may stop taking prescribed drugs once they start to feel better and I gave the example of the antibiotic side effects such as slight nausea are not considered allergic effects so anytime a patient says to you they have an allergy to something have them tell you what it is allergic effects may include a rash severe nausea and vomiting difficulty breathing a drop in blood pressure but specifically if a patient states they have an allergy ask them what the signs and symptoms they're experiencing in that algae because it really might not be a true allergy the health care provider has to determine what is causing the side effects or the allergic response and whether it's the medication or something else so you need to report that to the you know as I said you hold the medication when you have something concerned like this notify the prescriber immediately all right I have just a few um questions here these are classroom response questions now in the classroom we're going to be holding up cards that have a b c and d on them but this is just a good opportunity for you to think things through I don't want anybody you know in class to answer out loud I want you just to hold up the cards but here with this discussion obviously that we're not in a classroom situation and so you can just answer so the first question is um oh so I'm sorry sorry my classroom response questions or don't speak out loud don't discuss with your classmates answer for yourself only and hold up the card for the correct answer first question the nurse answers a patient's call light and is the patient sitting up in bed and requesting pain medication what will the nurse do first now our key to this question is literally the word first okay what's the nurse going to do first a check the orders and give the patient the requested pain medication B provide Comfort measures to the patient C assess the patient's pain and pain level D evaluate the effectiveness of previous pain medications so once again there's answers the patients call light finds the patient sitting up in bed requesting pain medication what will the nurse do first okay so again that's our keyword assess the patient's pain and pain level why let's go back to the nursing process assessment comes first I can't do anything until I assess their pain level am I going to check the orders and give them the required the requested pain medication I certainly am if it's okay for them to have it now am I going to provide Comfort measures to my patient I certainly am am I going to evaluate the effectiveness of previous pain medications yes I am but my question says what do I do first and first I need to know what my patient's pain level is second question patients medication administration record lists two anti-epileptic medications or anti-seizure meds that are due at nine o'clock but the patient is NPO or has nothing by mouth for a barium study the nurse's co-worker suggests giving the medication via the IV route because the patient is NPO what will the nurse do a give the medication by mouth with a small sip of water B give the medication by the IV route because the patient is NPO C hold the medication until after the test is completed D call the health care provider to clarify the instructions what am I going to do for my patient who has two anti-epileptic medications ordered but the patient is NPO I'm going to call the health care provider to clarify these instructions why well if you think about it if the patient's on two medications for seizures and I'm not giving those medications what's going to happen is their therapeutic blood level is going to drop and it may cause them to have seizures okay the day shift charge nurse is making rounds a patient tells the nurse that the night shift night shift a nurse never gave him his medication which was due at 2100 or 9 pm what will the nurse do first to determine whether the medication was given a call the night nurse at home B check the medication administration record C call the pharmacy d review the nurse's notes looks like that last answer is not fully bolded but they're all supposed to be equal okay so day shift Chargers making rounds patient tells the nurse he didn't get his med last night at nine o'clock what should the nurse do first to see whether or not the medication was given once again our keyword is first there may be more than one thing on this list we're going to do but we definitely want to know what to do first this is our last slide coming up by the way check the medication administration record now remember if the nurse gave the medication like they were supposed to they would have documented it like they were supposed to so that means the mar the medication administration record should have notation that the med was given we only document after we give the medication so what if the mar shows that it wasn't written down what do you think you're going to do next yeah reviews the nurses notes maybe the nurse made a comment in the nurse's notes of why the medication wasn't given calling the pharmacy is not going to help at all they have no idea whether the nurse gave or didn't give the medication so if I check the mar it's not signed off if I check the nurse's notes there's no note in there I have only one recourse and that is to call the night nurse at home did you get the medication okay I hope that was helpful and I'll be talking to you later

we&#39;re beginning with chapter one pharmacology in the nursing process in LPN practice LPNs an important role in giving nursing care providing care to their patients and the responsibilities of the LPN slash LVN are really predicted to grow because more and more excuse me RNs are leaving the workforce and they&#39;re not necessarily replacing them with other RNs so LPNs are being um hired in those roles now more tasks of the RN will be delegated to the LPN slash LVN LVN is just a licensed vocational nurse they really pretty much mean the same thing and so delegation is when one person is assigning a task to another person now just be sure you understand and I&#39;ll mention this again the person who delegates is still responsible to make sure that whatever was delegated gets done it&#39;s part of accountability LPNs and LVN should understand clearly how to proceed in an organized way as they plan care for patients and then um obviously because the roles and responsibilities are going to be changing the LPN obviously needs to learn how to use the latest equipment um you know and whatever they may be having to be involved with so the lpn&#39;s responsibilities are as I said continually changing so it&#39;s very important to know what the nurse Practice Act says in your state every state has its own nurse Practice Act now notice that the slide says the RN licensure and authority to carry out all steps of the nursing process this differs from the LPN the LPN Works under the supervision of the RN to assess Implement and evaluate with guidance now we&#39;re going to talk about the nursing process in just a second but it has five pieces assessment diagnosis planning implementation and evaluation and you&#39;ll notice here that it does not state that the LPN is involved in diagnosis and planning but with that said it just means that the LPN doesn&#39;t do the initial assessment the LPN cannot formulate the diagnosis even though the LPN provides information and supports the formation of that diagnosis and the same thing is true of the initial planning the RN has to write out the plan for the patient&#39;s care but the LPN contributes tremendously to all of these steps LPNs practice in nursing homes Assisted Living agencies outpatients clinics Home Health agencies hospices rehabs LPN is involved in Drug Administration they have a very significant role as if many of you know in many facilities it&#39;s the LPN who&#39;s carrying out that particular role so as I said there are five steps to the nursing process the nursing process is literally a framework for how the nursing profession practices it&#39;s a scientific standardized process that ensures quality patient care it assists the nurse in meeting the standards of care for the patients I mentioned accountability before and so I want to mention it again the nursing process facilitates a nurse&#39;s accountability for his or her practice if you&#39;re following the steps of the nursing process in order as you should it helps the nurse be accountable for what they are doing now here I&#39;m just showing you two ways to look at the nursing process add pie is the most common adpie assessment diagnosis planning implementation and evaluation you will find some literature that leaves out the word diagnosis and says analysis instead so instead of add pie we can use a little acronym and apple pie assessment analysis planning implementation and evaluation if you think about it when you do an assessment what do you do with that information you check your patients vitals you listen to their lungs you know you do all those things then what do you do write it down and walk away well don&#39;t you analyze that data what does it mean right is this an abnormal pulse is this you know abnormal heart sounds so you&#39;re analyzing the assessment data and with that you formulate in your mind what you think is the patient&#39;s potential problem that&#39;s a nursing diagnosis okay so they really mean the same thing it&#39;s just different words all right so I already mentioned what it is it&#39;s a framework for professional practice it guides nurses how we think how we act it&#39;s scientific it&#39;s standardized and I want to point out to you that the steps do need to be completed in order you can&#39;t Implement care before you assess your patient it doesn&#39;t make sense to say oh I&#39;m going to go give my patient Tylenol for their temperature but I haven&#39;t even taken their temperature you see what I&#39;m saying you assess then you carry out your your plan of care it does facilitate that nurse&#39;s accountability for their practices I said and so my next question is so what is the licensed practical nurses part responsibility whatever in the nursing process this is a diagram from your textbook and it&#39;s just showing you the various steps now you notice that we start with a big blue circle on the upper right assessment we&#39;re going to get objective and subjective data from that collection of information we&#39;re going to formulate a diagnosis or determine what our patient&#39;s problems are we&#39;re going to plan their care carry out the care and in this situation we&#39;re talking about giving meds so you&#39;ll see the nine rights of drug safe medication administration and then we evaluate we&#39;re looking for therapeutic effects and we&#39;re looking for adverse effects and so forth so again this is just showing you the picture that is in your textbook to help you understand the steps of the nursing process so assessment now I have given you um those of you that are watching this for class you were given uh what I call a packet of information we&#39;re giving I&#39;m giving you pieces each week as we go over new content and it&#39;s your note taking tool some of you may have this some of you may not but if you do have that packet I want to indicate for you that anything that is in red and underlined would be blanks in your packet so as you&#39;re taking notes you can fill in the blanks with this information so as I said assessment we&#39;re gathering information we get it by talking to our patient looking at them closely observing them getting signs and symptoms looking at old records reviewing material a patient may bring it&#39;s our database okay so with our database it does include the physical assessment of the patient&#39;s history so notice here we say the RN is legally assigned as the staff member who must perform the initial assessment for each patient so the RN has to get the initial assessment okay after that then the LPN can be assessing but initially it has to be an RN it involves looking listening carefully asking questions it&#39;s a process that helps you get information about the patient the patient&#39;s problems anything that may influence the choice of drug to be given to the patient so once again if we&#39;re going to get the physical assessment our patient&#39;s history review Systems and so forth there are two types of data that we talked about that we&#39;re going to collect subjective and objective and I know on your ticket to class one of the questions that you had was to differentiate between these two and give an example subjective data it&#39;s what the patient says so it&#39;s obtained through questioning information that can&#39;t be measured I ask my patient how their pain is I can&#39;t measure that they have to tell me okay if my patient feels like their heart is pounding in their chest I can measure their pulse but I cannot measure palpitations that is a sensation the patient experiences so it is subjective objective data on the other hand is what I can get through observation information that I can verify that I can measure another person I can get it on the physical exam I can obtain Vital Signs lab results because anybody who looks at that will come to the same conclusion in other words when I&#39;m checking the skin it&#39;s warm it&#39;s dry okay if I&#39;m attaining vital signs I have numbers to look at lab results numbers to look at so subject is what the patient says objective is what we can observe and that can be measured so where do we get our information well the main source obviously is our patient or the client right but sometimes that person maybe has Alzheimer&#39;s or it&#39;s a child or somebody who can&#39;t give us information so it might be the family member medical records are another source of information patient being the primary but medical records you can look at old charts old records obtain your patients history get information from other health care providers sometimes they have consult sometimes they have multiple problems where they&#39;re seeing many Physicians so data from those positions and then of course we&#39;ve already discussed the fact that lab results can also give us some of that information so when we are getting our objective data the previous slide was about our history okay patient telling us things family telling us things and so forth but our objective data is through the physical exam inspections the first part of the physical exam just looking at your patient observing them you can observe when you see a patient who is in distress you know they&#39;re breathing really rapidly you can see a patient who is clutching their incision area somebody with their hand over their head you know what I&#39;m saying you&#39;re looking observing but inspection is also General appearance things like that palpation now don&#39;t confuse this with palpitation that&#39;s a term I used in the previous slide about feeling your heart beating in your chest palpation is the is the act of feeling touching you know checking pulses you&#39;re actually palpating a pulse feeling um internal organs checking for edema in the ankles you&#39;re actually touching the skin you&#39;re palpating to feel for that swelling percussion detecting differences in vibrations through the skin this is not used much at all anymore but it is still used in some places and it&#39;s typically done by the RN not the LPN but let me give you an example of percussion you may not have ever heard this term before but we have what is called CVA tenderness costovertebral angle tenderness it&#39;s actually a sensation the person has when they have kidney problems and when you put your hand over the cost overtebral angle it&#39;s sort of on the rib cage on the side where people think their kidneys are located and then you put your hand there and I&#39;ll show you this in class and then you with your other hand you tap your hand over the patient&#39;s back and the vibration goes through there tissues and if their kidneys are inflamed it hurts if their kidneys are not inflamed they don&#39;t feel a sensation there okay auscultation listening with the stethoscope auscultation so factors to consider in assessing your patient okay so helpful information obtained for the drug history we need to get some information okay so current sometimes they&#39;re past use of drugs names dosages as well as over-the-counter meds that&#39;s OTC and just keep in mind just a little FYI many patients don&#39;t know why they&#39;re taking certain medications like they say I take this pill every day but I don&#39;t know what it&#39;s for okay so an understanding of the patient&#39;s current concurrent disease process is also going to be very helpful and what questions could you ask to determine whether patient understands the drug he or she is actually taking what kind of questions could you ask you know the person okay but we want to ask about what are they taking over the counter prescriptions what about alcohol and street drug use that&#39;s going to be important because they interact with many medications any alternative therapies herbals dietary supplements and so forth now if you were to say to my husband do you take any medications he would say to you no and he doesn&#39;t he doesn&#39;t take any medications but he takes a ton of herbals and dietary supplements a ton I&#39;m like I&#39;m saying close to 50. so you have to ask the question now let me say this to you what do you think is the number one reason we need to know if somebody&#39;s taking alternative therapies what would be the number one reason again I&#39;m just letting you think this through okay the biggest reason is because they interact with medications okay so if I have a patient who&#39;s on a blood thinner and they&#39;re taking certain herbal things they could interact and make the blood even thinner and the patient wouldn&#39;t clot when they need to okay they might be on a medication that is used for one thing and they take an uh supplement that actually cancels out the effects of that medication so it&#39;s very important to know any herbs the patient is taking so you have to ask have they had any problems with any medications you know ask about them do they have any allergies is there any disease or chronic condition that makes a certain medication specific for them to take or contraindicated for them to take what about signs and symptoms of the disease that they have you know that might explain the need for their medication all of that&#39;s important to find out and then growth and development which we&#39;ll talk about in chapter three growth and development I have under lifespan considerations because it affects how many of those medications work because if they&#39;re young they have immature organs if they&#39;re old they might have organs that are deteriorating so we need to know things about growth and development all right so assessment our next phase is diagnosis the diagnosis is a conclusion about what the patient&#39;s problems are so a physician makes a medical diagnosis okay the nurse makes a nursing diagnosis please note that the medical diagnosis is not in the scope of the RN or the LPN and then the nursing diagnosis is also not in the scope of the LPN it is an RN&#39;s responsibility but the LPN can contribute to it okay so pernanda North American nursing diagnosis Association a nursing diagnosis is a clinical judgment concerning a human response to a health condition or life process so I said to you a little bit earlier that um when We Gather our data that&#39;s our assessment and we analyze that data we pretty much are coming to a conclusion all right we&#39;re coming to a clue conclusion about our patients response to their medical diagnosis we might have a patient with a hip fracture that&#39;s their medical diagnosis but as a result of that they have acute pain that is actually a nursing diagnosis as a result of that hip fracture they have impaired physical Mobility that&#39;s a nursing diagnosis a classic one for pharmacology and drug therapy is deficient knowledge related to drug therapy you know they have a new medication and as I mentioned earlier there are many patients who actually don&#39;t even know what medications they&#39;re taking and why so deficient knowledge right that&#39;s why we have to educate them so after assessment the nurse determines the nursing diagnosis as I said the RN makes the nursing diagnosis the LPN contributes information to it some questions to ask for developing a nursing diagnosis or what are the major health related problems for the patient what drugs are the patients taking what are the required what special knowledge or equipment is required to give those drugs what special concerns or cultural beliefs you know does the patient have how much does a patient understand about the medications and stuff that&#39;s being prescribed for them and what factors affect the patient&#39;s ability to care for themselves our next part of the nursing process is plan assessment diagnosis plan implementation evaluation so again notice in your notes that we have some blank so follow along the nursing diagnosis is made a plan of care is initiated that includes patient and nurse involvement please remember that nurses are Patient Advocates we work on their behalf that&#39;s what an advocate does you&#39;re working on the behalf of somebody else speaking up for somebody planning of care and establishment of goals is done in collaboration with the RN so what are we planning we&#39;re planning two major things we&#39;re planning goals and planning nursing orders or care so with our goals they&#39;re also referred to as outcomes okay they need to be patient centered a goal should never be something the nurse will do this it&#39;s the patient will okay so these could be short-term goals like we say as outcome statements so they can be a long-term goal that we want to see accomplished by discharge nursing orders our plan of action is going to help the nurse right their care plan help the client meet the goal okay so there are going to be specific orders for administrative administering medications that&#39;s what we&#39;re looking at here pharmacology so what are the factors to think about in planning to give a drug well first of all we need to even understand you know what&#39;s the reason the drug is given one medication might have four or five indications for example a beta blocker a beta blocker is typically a drug that we think affects the heart it can lower the heart rate it can lower blood pressure it can treat a dysrhythmia of the heart but it&#39;s also used for migraine headaches it&#39;s used for anxiety it&#39;s used to treat hyperthyroidism to slow down the heart so there&#39;s a lot of reasons for it wouldn&#39;t it make sense to you as a nurse to know why you&#39;re giving it because how are you going to know what to assess before you give it and to evaluate its Effectiveness if you don&#39;t know the reason they&#39;re getting it right learn information regarding the drug including the drug interactions as well as contraindications interactions how does one drug interact with another or even food alcohol and so forth contraindications a reason the patient shouldn&#39;t be getting the drug many contraindications could be because the patient has another condition or it could be something like a pregnant female shouldn&#39;t take this drug it&#39;s contraindicated during pregnancy right does that make sense plan for special storage techniques or equipment you know does it need to be refrigerated does it need can it be used only one time then it has to be disposed of things like that develop a teaching plan the RN is to perform the initial teaching in the LPN reinforces the teaching so what that means is the RN formulates the plan um you know once the RN formulates it of course the LPN can contribute to it but then the LPN can reinforce that teaching to the patient regularly prior to Drug Administration we have to apply critical thinking and so when we&#39;re looking at a drug order you know we have to verify first of all is this clear is it appropriate so what do we do what do we do if we question an order so prior to giving the drug verify the accuracy of the drug by checking the medication administration record we call this the mar it&#39;s the place where the drug order has been written it&#39;s usually copied from a doctor&#39;s order or if you work in a facility that has electronic medical records we call this the Emar it could be again you&#39;re checking against the provider&#39;s order determine whether the type of drug and dosages are appropriate for the patient you have to know this do not second guess or say to yourself well the doctor ordered it it must be okay no you verify if you have any questions so again critical thinking is essential you need to know and follow the nine rights what do you do if you question a drug order don&#39;t rely on information from your peers you are responsible for administering the drug know when to question an order and for what reasons and I&#39;m going to address that in just a second but I&#39;m telling you this is part of your responsibility as the nurse so you are looking at an order and you say that&#39;s not really clear oh it doesn&#39;t look like that&#39;s written correctly I&#39;ve never heard that dosage be that high before or you say the patient&#39;s condition would get worse if I gave him this drug their heart rate is already low if I give them this it&#39;s going to get even lower right The Physician didn&#39;t have all the relevant information needed before writing the order maybe there&#39;s some new information that has come about that the doctor didn&#39;t have and so he wrote this drug order and you&#39;re concerned about giving the medication maybe there&#39;s a change in your patient&#39;s condition any of those things these are all just examples of what would you do if you&#39;re questioning anything first off you do not give the drug the drug is withheld not given until the order is clarified and you&#39;re going to clarify it with the health care provider I want to emphasize this to you when you question order you have to check with a health care provider you&#39;re going to notify your charge nurse or your supervisor as well and so you want to know what your facility&#39;s policy is when you question an order but I&#39;m telling you as a nurse your responsibility is to question it with the health care provider factors to consider in planning to give a drug what&#39;s the drug supposed to do learn information about it okay so if I&#39;m going to give a medication to my patient I need to know its major action what is it supposed to do we call this mechanism of action and I gave you some examples already these are going to lower the heart rate is it going to you know treat anxiety is it going to treat a migraine headache is it going to cause them to have diarrhea like I want to know what is the drug supposed to do side effects that may develop that&#39;s normal side effects expected obviously what is the usual dosage what is the route and the frequency frequency how often do they get it you want to know what is normal situations in which the drug should not be given what are contraindications and we talked about that just a moment ago like pregnancy somebody has high blood pressure they shouldn&#39;t take certain decongestants because they stimulate the heart many drug interactions um I&#39;m just trying to think about many drug interactions just one second here I apologize for the delay um so once again back to this slide what&#39;s it supposed to do learn information about its actions expected side effects when would I not give it and then those drug interactions I mentioned before what things could possibly influence you know one drug given with another drug or given at the same time they might cancel out each other you know you just need to know that foreign also when we&#39;re planning we talked about that special equipment you know doesn&#39;t need to be shook um do is refrigerated Etc so review all that if there&#39;s any special technique like is it an inhaler or a patch or anything that you need to put on because sometimes a patch has to be taken off before the next one comes on and you move it from site to site so the skin doesn&#39;t get irritated but stuff like that develop a teaching plan for your patient to include what the patient needs to know about the drug what is its action what are the expected effects they need to know what&#39;s supposed to happen they also need to know what things may happen those expected side effects so what do they need to know to take the drug the correct way what do they need to report to the nurse or their provider if there&#39;s any problems they need to know those things so you need to teach them those items so assessment diagnosis planning implementation this involves following the care plan that you planned and giving the medicine accurately to the patient it requires the nurse use information learned about each patient and about each drug and then you&#39;re going to watch for changes in the patient&#39;s condition that may make it unwise to give the drug again don&#39;t just assume it&#39;s ordered I give it under implementation we have the nine rights and I had you um I had you put these on your ticket to class the nine rights of Drug Administration or the uh giving the right drug um right patient right drug write dose right route right time right reason right documentation right response and right to refuse so let&#39;s go over those the right patient it&#39;s important that you identify patients correctly using two unique identifiers ID number name date of birth but you&#39;re not going to say are you John Doe because a confused patient might answer to anything you need to ask them to State their name and date of birth or whatever your facility is using but have them tell you their name don&#39;t say are you compare it to the patient&#39;s identification bracelet their wristband make sure they match in a hospital setting you never give a drug to a patient who&#39;s not wearing an ID band you need to get them one okay many patients are at risk for misidentification for example those that can&#39;t effectively communicate you know P to geriatrics critically ill confused those will have English as a second language so in some some long-term care setting they use a client photo they might have it over the top of the bed and then they might have one in their Mar and that&#39;s how they verify their patients but you use what your facility does but I&#39;m telling you for testing purposes name and date of birth two unique identifiers but ask them to State their name and date of birth never identify a patient solely solely that means by itself their room number or their bed number never never okay right drug a wrong drug is a main reason for drug errors I mean we&#39;re all familiar with drug errors that we&#39;ve heard about and so forth people making these major mistakes and I&#39;m just saying it&#39;s very very important that you have the right medication verify the drug label with the orders or you&#39;re checking your medication record and once you have the order the order gets copied onto the mar that&#39;s a medication record so once it&#39;s on the medication record the nurse is checking the label on the medication with that medication record drug labels verified three times three times are before taking it from the unit dose card or the Shelf before preparing the prescribed dosage and then before preparing it at the patient&#39;s bedside giving it to them you&#39;re checking the label one last time because if you pour it into the medicine cup it&#39;s too late to check the label you you have to check it before you put in the medicine cup the right time for testing purposes and for the Pensacola area we&#39;re going to say um one hour before or one hour after the scheduled time so if medication is ordered for 9 A.M it can be given an hour before which is 8 A.M to an hour after which is 10 a.m so between 8 and 10 would be safe to give a regularly scheduled nine o&#39;clock medication now there are exceptions for example insulin okay we um well you don&#39;t necessarily know this yet you&#39;re going to learn this there are many types of insulin that must be given within 15 minutes of a meal so I don&#39;t have that two hour window an hour before or an hour after it&#39;s ordered if it says insulin with breakfast it means insulin with breakfast does that make sense sometimes medication is in order to give 15 minutes prior to X then it has to be given 15 minutes prior to X but I&#39;m just talking about routine scheduled medications an hour before an hour after it&#39;s scheduled any special considerations know the action of the drug that&#39;s going to affect the time a diuretic which is a water pill I&#39;m going to give that during the early part of the day not at bedtime right they&#39;re going to get up all night I have to go to the bathroom a stat and that&#39;s a cholesterol lowering drug statins work best between midnight and 5 a.m when cholesterol is being synthesized or manufactured in the body so it&#39;s best to give a Statin drug in the evening so it can be working while the body would naturally be producing cholesterol but know your hospital policies and patient routines all of that is part of what makes the timing right but look at the order what does the order say if the order is given a specific time follow it if you question that once again go back and question it with a prescriber right reason you need to know the reason the patient&#39;s getting it is I&#39;ve discussed with you already what is the rationale for the use of this medication and does it even make sense for your patient does it make sense that this patient&#39;s getting that medication know your patients know the drugs they&#39;re getting okay the right dose considerations include age weight their health status any changes in their health status do you have the proper equipment is it the proper drug form the proper concentration I want to mention to you with form um that a form only matters when it&#39;s been ordered a specific way let me so for example the doctor says give such and such a medication po that means by mouth but he doesn&#39;t say liquid tablet and terracotta it just says by mouth if it&#39;s ordered by mouth it can be any of those forms so it can be a tablet it can be a capsule it can be a liquid but if it&#39;s ordered to be a special form like enteric coded or if it&#39;s ordered to be a sustained release medication then it has to be in that form so again depends upon whether or not it&#39;s ordered in a particular form the proper concentration your accurate dosage calculation which we&#39;re going to be doing in class frequently is calculating dosages for practice but always verify and clarify when you are in doubt some facilities actually require double checks by another nurse when calculations are required and it&#39;s highly recommended to help prevent error the right route don&#39;t assume the route if it&#39;s not ordered by a particular route you&#39;re going to say well how is this supposed to be given now if it&#39;s a medication that&#39;s only given one way you know that&#39;s another story but otherwise look further out routes alter the effects of a drug can affect the dosage um most drugs are given by the enteral route which is the gastrointestinal route in other words something a person is going to put in their mouth it is the most unreliable route though for absorption because GI tract is highly variable in people things like food in the stomach acidity of the stomach you know all those things can affect absorption nurses can&#39;t alter the route of a prescribed medication without a physician&#39;s order so if you do have to change a route be sure that you call the prescriber and get that order you can&#39;t just do it on your own note that the route and form are not the same thing as I just mentioned to you okay the route is by mouth but the form could be a liquid a capsule a tablet Etc consider for the oral route you know how many different ways um you know differences of medications that can be oral and we just went through all that different forms that can be oral as I said the enteral route is the most unreliable because a lot of factors affect absorption the enteral route involves swallowing and it&#39;s the only route affected by the first pass effect now this is number 28 in your list of terms in your packet it&#39;s also in your textbook under the terminology Within Chapter One um the first pass effect and what I want to tell you about the first pass effect is the first pass effect means that when a medication is swallowed it has a metabolism in the liver prior to getting out to the rest of the body where a lot of the medication becomes inactive so typically if it has a first pass effect the dosage is going to be higher because you&#39;re going to lose some in that initial metabolism by the liver and less of it is going to actually get into the bloodstream okay so typically with a first pass effect higher dose initially because you&#39;re going to lose some and the first pass effect only applies to medications that are taken in by mouth that you swallow so sublingual is in the mouth but you&#39;re not swallowing it sublingual goes under the tongue notice also that drugs should never be left at the patient&#39;s bedside for them to take later right documentation we&#39;re going to document on the mar our medication administration record if a patient is receiving PRN medications we&#39;re also going to document that in the nurse&#39;s notes as well as the patient&#39;s response so what that means is if my patient has a headache and they&#39;ve asked for some Tylenol for their headache I&#39;m going to mark it in the mar when I give them the Tylenol but I&#39;m going to put in the nurse notes the patient had a headache and I&#39;m going to ask them to describe it a scale of 0 to 10 with 0 being no pain 10 being the you know most pain they&#39;ve ever experienced rate their pain I&#39;m going to document that and then after about an hour when I&#39;ve given that medication a chance to work I&#39;m going to evaluate its response and then I want to chart that too so but with documentation I&#39;m just stating you don&#39;t want to document till you give it you only document what you give you never give a drug that you don&#39;t prepare never never if you have a nurse at clinical that says to you here give this medication but you didn&#39;t prepare it don&#39;t do it if you have a nursing instructor who says to you here give this and they hand it to you but you didn&#39;t I&#39;m saying like I already put it in a syringe I&#39;m not saying they hand you something in a package you can still verify that&#39;s a correct medication but if you didn&#39;t put it in that syringe don&#39;t give it and you tell them that you when you go to your clinical orientation you&#39;re going to sign something that says you&#39;re not going to give a medication you didn&#39;t prepare so you have something to back this on um document accurately after the drug is administered remember if it isn&#39;t documented it isn&#39;t done okay and the patient&#39;s right response know what the medication is intended to do because again if it&#39;s supposed to lower blood pressure how am I going to know if I don&#39;t even know that&#39;s the reason that they got it continually evaluate the achievement of desired effect did it lower the blood pressure did it decrease their pain did it increase their urine output in other words what is it given for and then I want to know did it work side effects mantra for adverse effects what is the difference in a side effect and adverse effect we often use the terms interchangeably but they&#39;re really not a side effect is something that really is almost expected so let&#39;s say for example somebody takes a Benadryl for allergies an expected side effect it causes dry mouth it causes the person to get sleepy right most people know that that is a side effect adverse effects could be something like anaphylaxis where somebody breaks out into a rash their throat starts to swell their blood pressure drops that&#39;s really really serious that&#39;s an adverse effect okay and then of course we&#39;re going to document we want to document what it was supposed to do did it do it and whether any adverse effects or side effects document those as well patients have a right to refuse a drug now this is just based upon the principle of autonomy everybody has a right to manage their own care all right so you talk to the patient first and find out why did they refuse the medication sometimes it&#39;s just a lack of understanding about what the drug is going to do you want to educate them first so say why why do you not want this medication and they say oh it makes me feel so blah blah blah or when I take this it upsets my stomach well sometimes we can actually say well let&#39;s try taking it with a little bit of food okay even when a medication is supposed to be taken on an empty stomach if it makes them sick to their stomach it is still recommended to give it to them with a snack or a little bit of food so that they will take it because what&#39;s better taking it with a little bit of food when it&#39;s supposed to be on an empty stomach or them not taking it at all right at least they&#39;re getting it if you can give it to them with a snack so find out why educate them maybe it&#39;s an antibiotic and the patient says I feel good now I don&#39;t need any more of my antibiotic well the correct response is in order for this antibiotic to be effective you have to take it for the full cycle because what happens is the antibiotic is weakening the bacteria but it&#39;s not going to destroy it until you have a therapeutic blood level for a significant amount of time and what that does is it makes the bacteria that&#39;s causing this infection actually get stronger it produces drug resistance so patients need to understand this if they still refuse you&#39;re going to document this in the medical record you&#39;re going to notify the prescriber per whatever protocol your facility has so it&#39;s very important that you document it and that you notify so my question is this what is the nurse&#39;s responsibility when a patient refuses their medication educate and document okay if you educate them they may take the medication but whether they do or they don&#39;t document that they refused the reason why they refused that you educated them about the medication that&#39;s very important to include in the documentation right education use every opportunity to teach your patients and family about their meds include ways to enhance the drug therapy with diet exercise you know lifestyle changes you know maybe they&#39;re taking like I say a Statin drug to lower their cholesterol well what else can help with their cholesterol Believe It or Not exercise helps lower cholesterol educate about what the medication is intended to do what&#39;s its purpose because again if they don&#39;t know you know they&#39;re not even going to understand so educate them about it it&#39;s also important to educate about potential side effects so they can be looking for those side effects can be a main reason for non-compliance think about this patient doesn&#39;t like the way a medication makes them feel so they stop taking it but if you explain to them the side effects it may help them to be more compliant understanding this is a normal side effect my mouth getting dry is expected I just need to continue taking my medication now if they&#39;re on a medication that has a nasty side effect they&#39;ve been told about it and if that side effect occurs you might say to them notify your prescriber if this becomes uncomfortable for you because they may need to give you a different medication but non-compliance a main reason for that is not liking the side effects of medication and educating the patient will help reduce them being non-compliant our last part of the nursing process is evaluation it&#39;s the process of determining the right response looking what happens to the patient when the nursing care plan is put into action it requires you to watch their patient to for that correct response noting both expected and unexpected findings helps the healthcare team decide whether to continue with the same drug or make changes I mean you think about it we&#39;re looking at saying did the medication work did it do what it&#39;s supposed to do or did it have adverse effects I want to document both my question to you here is what is the difference between assessment and evaluation right so let&#39;s stop and think what am I doing when I assess what am I doing when I evaluate okay oh I&#39;m sorry I thought I had the answer on here let me go back I thought I had it right there interestingly I don&#39;t have it on that slide so let me just go ahead and say what I was going to say I must not have saved the difference in assessment and evaluation okay they are both assessment both are assessment I assess my patient&#39;s blood pressure before I give them their antihypertensive okay I&#39;m writing it down it&#39;s 156 over 86 I&#39;m writing it down I give them the medication I allow the medication time to work and now I&#39;m going to go evaluate the effectiveness and what do I do I assess the blood pressure again does that make sense so assessment per se is prior to your nursing intervention evaluation is after the intervention all right now factors think about evaluating a response to drugs it&#39;s important for patients to understand the time frame which the therapeutic effects of a drug will occur if I have a medication that&#39;s not going to show effects for about two weeks don&#39;t you think the patient should know that if you give a medication that&#39;s not going to show effects for about an hour they need to know that teaching is essential patients may stop taking prescribed drugs once they start to feel better and I gave the example of the antibiotic side effects such as slight nausea are not considered allergic effects so anytime a patient says to you they have an allergy to something have them tell you what it is allergic effects may include a rash severe nausea and vomiting difficulty breathing a drop in blood pressure but specifically if a patient states they have an allergy ask them what the signs and symptoms they&#39;re experiencing in that algae because it really might not be a true allergy the health care provider has to determine what is causing the side effects or the allergic response and whether it&#39;s the medication or something else so you need to report that to the you know as I said you hold the medication when you have something concerned like this notify the prescriber immediately all right I have just a few um questions here these are classroom response questions now in the classroom we&#39;re going to be holding up cards that have a b c and d on them but this is just a good opportunity for you to think things through I don&#39;t want anybody you know in class to answer out loud I want you just to hold up the cards but here with this discussion obviously that we&#39;re not in a classroom situation and so you can just answer so the first question is um oh so I&#39;m sorry sorry my classroom response questions or don&#39;t speak out loud don&#39;t discuss with your classmates answer for yourself only and hold up the card for the correct answer first question the nurse answers a patient&#39;s call light and is the patient sitting up in bed and requesting pain medication what will the nurse do first now our key to this question is literally the word first okay what&#39;s the nurse going to do first a check the orders and give the patient the requested pain medication B provide Comfort measures to the patient C assess the patient&#39;s pain and pain level D evaluate the effectiveness of previous pain medications so once again there&#39;s answers the patients call light finds the patient sitting up in bed requesting pain medication what will the nurse do first okay so again that&#39;s our keyword assess the patient&#39;s pain and pain level why let&#39;s go back to the nursing process assessment comes first I can&#39;t do anything until I assess their pain level am I going to check the orders and give them the required the requested pain medication I certainly am if it&#39;s okay for them to have it now am I going to provide Comfort measures to my patient I certainly am am I going to evaluate the effectiveness of previous pain medications yes I am but my question says what do I do first and first I need to know what my patient&#39;s pain level is second question patients medication administration record lists two anti-epileptic medications or anti-seizure meds that are due at nine o&#39;clock but the patient is NPO or has nothing by mouth for a barium study the nurse&#39;s co-worker suggests giving the medication via the IV route because the patient is NPO what will the nurse do a give the medication by mouth with a small sip of water B give the medication by the IV route because the patient is NPO C hold the medication until after the test is completed D call the health care provider to clarify the instructions what am I going to do for my patient who has two anti-epileptic medications ordered but the patient is NPO I&#39;m going to call the health care provider to clarify these instructions why well if you think about it if the patient&#39;s on two medications for seizures and I&#39;m not giving those medications what&#39;s going to happen is their therapeutic blood level is going to drop and it may cause them to have seizures okay the day shift charge nurse is making rounds a patient tells the nurse that the night shift night shift a nurse never gave him his medication which was due at 2100 or 9 pm what will the nurse do first to determine whether the medication was given a call the night nurse at home B check the medication administration record C call the pharmacy d review the nurse&#39;s notes looks like that last answer is not fully bolded but they&#39;re all supposed to be equal okay so day shift Chargers making rounds patient tells the nurse he didn&#39;t get his med last night at nine o&#39;clock what should the nurse do first to see whether or not the medication was given once again our keyword is first there may be more than one thing on this list we&#39;re going to do but we definitely want to know what to do first this is our last slide coming up by the way check the medication administration record now remember if the nurse gave the medication like they were supposed to they would have documented it like they were supposed to so that means the mar the medication administration record should have notation that the med was given we only document after we give the medication so what if the mar shows that it wasn&#39;t written down what do you think you&#39;re going to do next yeah reviews the nurses notes maybe the nurse made a comment in the nurse&#39;s notes of why the medication wasn&#39;t given calling the pharmacy is not going to help at all they have no idea whether the nurse gave or didn&#39;t give the medication so if I check the mar it&#39;s not signed off if I check the nurse&#39;s notes there&#39;s no note in there I have only one recourse and that is to call the night nurse at home did you get the medication okay I hope that was helpful and I&#39;ll be talking to you later

Transcript for:Chapter One: Pharmacology in the Nursing Process

Transcript for:
Chapter One: Pharmacology in the Nursing Process