Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide 8.5 The Nursing Process and Medication Safety Assessment Assessment related to medication safety must include an accurate history and physical exam. • History: o A complete and accurate health history will assist the nurse in understanding the patient's knowledge about health and medications, in addition to any conditions that may affect the effectiveness of medications. The nurse must obtain information about: § Acute or chronic health problems that the patient may be suffering from § Allergies to medications or foods; food allergies are critical because many medications use food substances (e.g., eggs) as a base § The medications the patient is taking; this should include all herbs, minerals, vitamins, OTC medications, and prescription medicines; the nursemust document the drug, dose, frequency of use, time of last dose, and route § The patient's knowledge about the drugs being taken • Physical exam: o The patient's general health status must be assessed to determine the sufficiency of the current drug therapy. o Nutritional status should be assessed to determine if there are issues that might change absorption of medications. o The patient's vital signs should be taken to determine a baseline for comparing therapeutic or adverse effects of drugs. o Any cognitive impairment should be identified to ensure the patient is able to understand and follow a medication regimen. • Psychological exam: o The patient's motivation to follow a regimen must be determined. o If there is evidence that a patient does not follow other care regimens, the nurse must suspect that medication regimens may not be followed. o Emotional issues and stress may impair the patient's ability to follow a medication regimen. Analysis and Diagnosis When the initial assessment is complete, the nurse and patient must use the assessment data to identify nursing diagnoses that will drive the patient's plan of care. Appropriate nursing diagnoses related to medication safety might include: • Health maintenance, ineffective • Knowledge, deficient • Noncompliance • Poisoning, risk for • Therapeutic regimen management, effective or ineffective

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