The document outlines the role of the RN in medication assessment and administration. It discusses collecting a thorough drug history, medical history, and physical exam. The RN is responsible for creating a medication profile, identifying all substances taken by the client, and considering factors like development, allergies, and organ function. Proper assessment involves open-ended questions, vital signs, and a holistic approach. The RN prioritizes nursing diagnoses, sets goals, and follows the eight rights of administration to ensure safety. Monitoring the client and effects of the drugs is also important.

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