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Role of the RN in Medication Assessment &
Administration
Drug History (Allergies, Prescription,
Drugs taken, Over-the-Counter Drugs
used).
Medical History (Biographical data,
Lifestyle and beliefs, Sensory and
cognitive status).
Physical Examination.
Collect Subjective & Objective
data: Client, Drug & Environment
Use current Drug handbook/text
reference/ licensed pharmacist
Create a medication profile
OTC meds (e.g. aspirin, vitamins, dietary
supplements, NSAIDS, laxatives, dietary
supplements, antacids, minerals,
elements)
Prescription Medications (e.g. birth
control pills, hormone replacements,
drugs for sexual dysfunction)
Street drugs (e.g. marijuana, cocaine,
Herbals & homeopathic substances
Problems with drug therapy in the
past (e.g., allergies, adverse
effects, diseases or injuries, organ
pathology)
Growth & development issues as
related to the client’s age and
specific expectations (
 Establish a therapeutic relationship with
client
 Use open ended questions (avoid “yes” or
“No” answers)
Questions/content of questions should include:
 Oral intake of client: how does client tolerate
fluids
 swallow problems
 Laboratory/diagnostic test value e.g. renal,
liver panels, hgb/hct., protein, albumin
levels.
 Consider client’s experience with meds/health
care system, previous hosp.
 Check vital signs (establish baseline)
 List meds client is taking /how taken/when
 List new meds ordered
 Use holistic framework- identify emotional,
physical, cognitive, cultural & socioeconomic
factors impacting drug therapy & nursing process
Prioritize the nursing diagnosis
Specify objective, measurable, realistic
goals
Establish a time period for achievement of
outcomes
If order is in question- do not give- call
physician for clarification/further
instructions.
Health Maintenance, Altered.
Knowledge Deficit.
Management of Therapeutic Regimen,
Ineffective.
Physical Mobility, Impaired.
Sensory/Perceptual Alterations.
Assessment.
 Administration.
 Teaching.
Primary nursing interventions related to
medication management are:
 Requires constant communication & collaboration with
client& health care team
 Follow the “eight rights”:
 Right patient
 Right medication
 Right dose
 Right route
 Right time
 Right documentation
 Right reason
 Right response
Right to a “double check”
Right to proper
storage/documentation
Right to accurate calculation&
preparation
Right to careful checking of
transcription of orders
Client safety- use of correct
administration procedures
Right to close consideration of
special situations e.g.: difficulty with
swallowing, client with NG tube or
who is unconscious
Right to having all measures taken
to prevent and report med errors if
they occur
Right to individualized /complete
client teaching
Monitor client responses to the
drug
Monitor expected and
unexpected responses
Monitor therapeutic (intended
effects), side effects , adverse
effects & toxic effects
Words are the most
powerful drugused
by mankind.
~Rudyard Kipling

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Nursing Process for Drug Administration

  • 1. Role of the RN in Medication Assessment & Administration
  • 2. Drug History (Allergies, Prescription, Drugs taken, Over-the-Counter Drugs used). Medical History (Biographical data, Lifestyle and beliefs, Sensory and cognitive status). Physical Examination.
  • 3. Collect Subjective & Objective data: Client, Drug & Environment Use current Drug handbook/text reference/ licensed pharmacist Create a medication profile
  • 4. OTC meds (e.g. aspirin, vitamins, dietary supplements, NSAIDS, laxatives, dietary supplements, antacids, minerals, elements) Prescription Medications (e.g. birth control pills, hormone replacements, drugs for sexual dysfunction) Street drugs (e.g. marijuana, cocaine,
  • 5. Herbals & homeopathic substances Problems with drug therapy in the past (e.g., allergies, adverse effects, diseases or injuries, organ pathology) Growth & development issues as related to the client’s age and specific expectations (
  • 6.  Establish a therapeutic relationship with client  Use open ended questions (avoid “yes” or “No” answers) Questions/content of questions should include:  Oral intake of client: how does client tolerate fluids  swallow problems  Laboratory/diagnostic test value e.g. renal, liver panels, hgb/hct., protein, albumin levels.
  • 7.  Consider client’s experience with meds/health care system, previous hosp.  Check vital signs (establish baseline)  List meds client is taking /how taken/when  List new meds ordered  Use holistic framework- identify emotional, physical, cognitive, cultural & socioeconomic factors impacting drug therapy & nursing process
  • 8. Prioritize the nursing diagnosis Specify objective, measurable, realistic goals Establish a time period for achievement of outcomes If order is in question- do not give- call physician for clarification/further instructions.
  • 9. Health Maintenance, Altered. Knowledge Deficit. Management of Therapeutic Regimen, Ineffective. Physical Mobility, Impaired. Sensory/Perceptual Alterations.
  • 10. Assessment.  Administration.  Teaching. Primary nursing interventions related to medication management are:
  • 11.  Requires constant communication & collaboration with client& health care team  Follow the “eight rights”:  Right patient  Right medication  Right dose  Right route  Right time  Right documentation  Right reason  Right response
  • 12. Right to a “double check” Right to proper storage/documentation Right to accurate calculation& preparation Right to careful checking of transcription of orders Client safety- use of correct administration procedures
  • 13. Right to close consideration of special situations e.g.: difficulty with swallowing, client with NG tube or who is unconscious Right to having all measures taken to prevent and report med errors if they occur Right to individualized /complete client teaching
  • 14. Monitor client responses to the drug Monitor expected and unexpected responses Monitor therapeutic (intended effects), side effects , adverse effects & toxic effects
  • 15. Words are the most powerful drugused by mankind. ~Rudyard Kipling