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Файл:Clinical nursing practice. Study aid for foreign students of medical university
.pdf
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• The original assessment of risk and the original assessment of any
wound.
• Any unexpected effects of particular products used. For example,
any problems encountered in obtaining, using, maintaining or repairing
aids and equipment, or dressing materials. It may be necessary to draw
these comments to the attention of managers, pharmacists, maintenance
and supplies departments and manufacturers.
• The person's feelings and response to his or her care. It is vital that
nurses do not underestimate the pain and distress which a pressure sore,
and the long-term treatment that is often required, can cause to an individual and his or her families and friends. Evaluation and reassessment needs
to be holistic, taking into account the possibility of socio-economic or psychological consequences and problems, as well as the more obvious physical effects of the sore and its management.
• The quality of care that has been provided (at each stage of the
nursing process) and whether agreed standards of care have been maintained, or not.
6.8. CONCLUSION
In this section we have reviewed some of the research evidence currently available to guide nursing practice in the prevention and management of pressure sores. Pressure sores are a problem which as a nurse, you
will encounter frequently, in most care settings.
When a patient/client develops a pressure sore, it is often cited as evidence of “poor nursing care” or “a lack of nursing care”, because as nurses, we usually have responsibility for the prevention and management of
pressure sores. Statements such as this imply that nursing care has in some
way been negligent, for example by not turning the person often enough or
failing to maintain skin hygiene. Sometimes this may be true. But as the
preceding discussion of the factors associated with risk for pressure sore
development and the conditions needed for healthy tissue growth and repair illustrates, pressure sore prevention is extremely complex and many of
the factors lie beyond the influence of nursing.
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In order to care effectively for those at risk of pressure sores, however, nurses need a sound knowledge base, which includes access to research
findings and the current literature, as well as skills in the assessment, planning, implementation and evaluation of nursing care in this area of practice. The frequency with which we encounter wounds and pressure sores
can account, to some degree, for our lack of knowledge of research findings. When a problem is part of our everyday practice, it can be easy to assume that we already “know” about the subject and that we are already
providing a good standard of care.
In reality, there is considerable ongoing development in both wound
care and pressure sore prevention. It can come as a surprise to you to learn
that something which we were taught as good practice (such as regular
rubbing of pressure points with soap and water) is in fact harmful, and that
for many years we may have been harming rather than helping our patients/clients by this practice. We cannot afford to become complacent about
what we know. Professional practice demands a positive attitude in which
we question ourselves, others and the very knowledge on which we base
our thoughts and actions. In order to provide the best possible standards of
care, we need to reflect on our practice regularly in the light of new research findings and clinical developments. Such critical thinking means
that often we will find our practice wanting and requiring us to change either what we do or how we do it.
Many of the recent developments in pressure sore prevention and
wound healing have considerable resource implications if they are to be
adopted in practice. As nurses, we should not be professionally compromised by being put in a position where we are forced to provide an unacceptable standard of care through lack of policy development and man-
agement support. Much “product development” activity tends to follow
from research findings and “new understandings” of old and complex
problems such as pressure sores. Nurses and other health care workers
need the knowledge and skills critically to evaluate research findings and
to distinguish marketing hype from proven efficacy and cost-effectiveness
in new product developments.
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Decisions about the purchasing of resources and supplies need to be
made within the wider context of the health care system and budgetary
constraints, often at a hospital level. Whilst final decisions may not lie
with nurses, we must have a voice in such decision-making processes.
Hospital budget allocations and policy decisions frequently favor hightechnology medical treatment for a few, very sick patients at the expense
of preventative and supportive nursing and medical care that would benefit
many more people in the longer term.
We are accountable for our practice and must make other disciplines,
policy makers and managers aware of any limitations in existing practice
and of the resource implications of achieving an appropriate and agreed
level of care. Remember that managers and policy makers are also accountable for their actions. If nurses develop agreed clinical standards of
care, based on research evidence where available, managers will no longer
be able simply to “leave nurses to deal with pressure sores” with few, if
any resources to help them.
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7. ADMINISTRATION OF MEDICATIONS
7.1. INTRODUCTION
In this section you will examine your role and responsibilities as
a nurse in the safe administration of medications. The section will emphasize the importance of a sound knowledge base in the drugs that are administered, together with information about the individual for whom
a medication is prescribed.
The section will describe the usual routes of administration and guidelines for safe administration of drugs. This is followed by a summary of
the important aspect of patient/client teaching in relation to medications.
You will also look at evaluating drug administration, including issues of
non-compliance and the effect of individual, social and cultural factors in
affecting outcome. The concluding discussion for this section looks briefly
at the issue of trying to maintain safety standards in drug administration
and the problem of undeclared drug errors.
The learning objectives for this section are:
1. To improve your awareness of the knowledge base nurses need to
support their role in the safe administration of medications.
2. To review the different methods of drug administration.
3. To develop a teaching plan for a patient/client in relation to their
medications.
4. To consider your local policy on drug administration and the re-
porting of drug errors, in relation to the discussion on encouraging an open
and honest climate in which people are able to report mistakes they make.
7.2. THE ROLE OF THE NURSE
IN THE ADMINISTRATION OF MEDICATION
The prescribing of drugs is a medical responsibility. Within a hospital ward or department, however, nurses are responsible for the safe custody and administration of drugs. These are both legal and professional responsibilities. Even where the patient/client administers his or her own
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medication, nursing staff in hospital and community settings will often
have a role in patient/client teaching and in monitoring compliance and the
effects of drugs.
The administration of medications is not simply a delegated medical
duty. As nurses, we have a responsibility to think critically about this role
in the same way as for those activities which are primarily a nursing responsibility. It could be said that at one time, the nurse's responsibility regarding medication was limited to a simple formula, namely to give:
• The right drug, to.
• The right patient, in.
• The right dose, by.
• The right route, at.
• The right time.
Although as a basic rule, this principle still applies, there is more to
the nurse's role than merely ensuring that drugs are administered as prescribed. Simple correct administration alone cannot ensure that the treatment will result in the maximum benefit for the patient/client and, more
importantly, cannot ensure that there will be a minimum of harm. Medication is such an important part of modem health care, and modem drugs are
so powerful, that nurses, with their medical and pharmacology colleagues,
participate in a system of checks and balances designed to promote the
greatest good for the patient/client while doing the least harm.
Nurses, it can be argued, are especially important in this system. It is
they who observe and monitor the condition of their patients/clients most
closely. As a result, nurses may be the first to observe a patient/client’s reactions to the drugs he or she has been given. It follows that, in order to be
able to intervene appropriately, the nurse must know what these responses
are likely to be.
7.3. NURSES’ RESPONSIBILITIES
IN THE ADMINISTRATION OF MEDICATIONS
Professional accountability extends beyond simply “giving” a medication. Nurses should be able to recognize prescribing errors and to ques-
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tion incorrect or “unusual” prescriptions. We must be proactive in monitoring unwanted reactions and side-effects to drugs, and in drawing these
to the attention of medical staff, and in watching for omissions and errors
in drug administration.
Many drugs, such as analgesics, are prescribed in such a way that the
frequency or dosage (within certain parameters) of administration is decided by nursing staff. Certain drugs have more than one application or can be
administered by more than one route. Oral doses of morphine, for example, are generally much larger than those that are meant to be injected. In
the administration of medications, the nurse is the patient/client’s last line
of defense against errors. The professional practice of nursing means that it
is not enough for nurses just to “do”. We must at all times be “thinking
doers”.
To fulfil this role in administering medication and observing the patient/client for both desirable and desirable effects, in any given situation,
nurses need a knowledge both of the drug and the person it is prescribed for.
Knowledge of the drug needs to include:
• The drug's main pharmacological action.
• The usual dose range.
• The dose interval.
• The route.
• The desired effect.
• Any contraindications to its use.
• Any potential adverse reactions or side effects.
• How it interacts with other drugs.
Medical staff obviously have a primary responsibility for assessing
the indications for prescribing a particular drug and obtaining as detailed
a history as possible before prescribing. Obtaining information about the
person through assessment provides the context in which the drug will act.
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7.4. ASSESSING THE PERSON
The nurse as well as the doctor has a responsibility to assess the patient/client before administering any drug. This means not assuming that
medical staff will already have “checked” everything, or that the person
might not offer additional or different relevant information to nursing staff.
Assessing the person needs to include checking his or her past medical and
drug history, as well as the presenting history. No drug produces a single
effect. The combined effect of two or more drugs taken together may be
different from the effects of each when taken separately. Although this history taking may be viewed as repetitive by both nurse and patient/client,
some questions -such as whether there are any known allergies - cannot really be checked too many times.
The effect of a medication on human physiology and emotional state
does not depend only on the pharmacological properties of the drug. Factors such as personality, and social and cultural background can either enhance or reduce the effects of drugs and can explain some of the wide variation in different people's responses to medications.
It is important that the following information is collected and
interpreted:
1. Baseline data which is needed to be able to evaluate either thera-
peutic or adverse responses to a drug. Baseline data is essential if, for example, we give drugs that lower blood pressure. Without knowing what
the blood pressure was originally, we would have no way of knowing the
effect of the treatment.
2. The presence of any “high-risk” factors. Multiple factors can pre-
dispose a particular patient or client to adverse reactions to specific drugs.
For example, a patient/client who is allergic to penicillin can, under extreme circumstances, die if given the drug. It is essential that allergies or
past allergic reactions are known and communicated to all those involved.
3. The person's capacity for self-care. This may change during the
course of treatment and should therefore be continually re-assessed. The
promotion of self-care wherever possible, however, should always be
a goal.
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4. The person's understanding, reaction to and feelings about his or
her condition and the prescribed medication.
Knowledge of the person needs to include:
• The person's past and present medical history, including whether
the person has any conditions such as diabetes, epilepsy, or anemia.
• The reason the drug has been prescribed and the desired effect
sought for this particular person.
• Any other prescribed (or non-prescribed) drugs which the person is
taking, for example, anticoagulants, steroids, alcohol.
• Baseline observations of any clinical parameters which might be
expected to change.
• Any known allergies or drug idiosyncrasies.
• The person's understanding of his or her condition and why the
drug has been prescribed.
• The person's feelings about his or her condition and the pre-
scribed drug.
• The person's ability to store safely and to administer his or her own
medications, if appropriate.
7.5. IMPLEMENTING CARE
Administering medications. The nurse plays just as important a role
in the person's therapy as the drug itself. The manner in which the drug is
administered is all important in developing the person's confidence in the
treatment. It is important to remember that many patients/clients may be
frightened of injections or of the administration of any drugs at all. The
person will be influenced by the environment he or she is in, including the
nurse's attitude and the drug being administered. Explaining the purpose of
the drug that you are giving can be a powerful adjunct to the treatment.
Drug administration policies and procedures vary between hospitals
but the following guidance may aid correct administration.
Safe administration in hospital:
1. When administering medication, it is important to consult the pa-
tient's prescription chart:
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• Read the prescription carefully. If it is unclear, check with the mem-
ber of staff who issued it.
• Verify the identity of the patient/client along with the prescription
chart.
• Check the medication label, the amount to be given and the suita-
bility of the route proposed.
• Check the label on the medication container against the prescrip-
tion, both when removing the drug from the container and when replacing
the container in the drug trolley.
• No medication should be dispensed that is not taken directly from
its container.
• Verify any dose calculations required.
2. The patient's identity should be checked carefully, with particular
care being taken where two patients have similar names or are being given
medications with similar names: do not administer any drug if you do not
understand the reason for its prescription. Remember that each of us is responsible for our own professional actions
3. The patient/client should, as far as is possible, understand what the
medication they are taking is for and be able to discuss any concerns about
it in advance.
4. The medicine trolley should always be observed while unlocked,
and must be locked again immediately after use.
5. Any liquid medicines should be mixed thoroughly.
6. Protein preparations should be rotated gently to prevent denatura-
tion and frothing. They should be observed for any signs of discoloration
or foreign matter in the container. A note should also be made of the expiry date.
7. Give only medication that you or a pharmacist have prepared.
8. Check with the patient/client that any orally administered or self-
administered medication has been taken. For some patients/clients it will
be necessary to remain with the patient to ensure that the medication has
been taken. Complete a record that the drug has been given.
9. Observe the patient/client for signs that the medication is having
beneficial or adverse effects.
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Methods of administration. There are a number of ways of administering drugs. The main ones are by mouth, under the tongue, via the rectum, via injection, via topical application, via inhalation and by slow-release
formulation.
By mouth. Oral administration is the easiest, most acceptable and
safest method of drug administration, particularly if the person is to continue treatment at home. Orally administered drugs should be offered to
the person accompanied by a drink (excepting sub-lingual administration).
The drug may be administered in solid form, as a suspension or as an
elixir.
Orally administered drugs may be kept in the mouth and then absorbed into the blood stream via the buccal mucosa, or they may be swallowed and absorbed into the blood stream via the stomach or through the
small bowel. Sublingual tablets are placed under the tongue; buccal tablets
are placed in the pouch between the cheek and the gum. The speed at
which the drug is absorbed and the amount of active drug that is available
for use depends on several factors, including the form in which it is given
(for example, whether as a tablet or as a liquid) and whether it is taken
with food or on an empty stomach. If a drug is taken when the stomach is
empty, it may act more quickly than when the stomach is full.
Some drugs such as antacids, which neutralize stomach acidity, are
taken by mouth to produce a direct effect on the stomach or digestive tract.
Others, such as vancomycin, have beneficial effects on other parts of the
gastrointestinal tract.
Avoid direct contact with tablets because of the risk of sensitization.
By injection. Drugs may be injected into the body to produce a systemic effect. One reason for injecting drugs is the rapid and reliable response that follows. Other reasons for injecting a drug would be to resist
inactivation by stomach acids or because of the drug's inability to pass
through the intestinal walls into the blood stream. Drug injections may also
be given to produce a local effect, such as to relieve the pain of arthritis.
The type of injection used, intravenous, intramuscular or subcutaneous, depends on the nature of the drug to be given and the condition being
treated (see tab. 13).
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