2.1 Drug Administration and the Nursing Process

Nursing Process

The nursing process is a method of critical thinking consisting of five steps that occur continuously while the client is in the nurse’s care. (The client may be an individual, a family, a group, or a community.) It is purposeful and systematic in its progression, designed to achieve optimal client outcomes. It is a framework for the nurse to apply scientific reasoning to client care. The steps to the nursing process are linear but overlap each other in their progression:

1. Assessment of the client
2. Diagnosis of actual or potential problems
3. Planning nursing interventions
4. Implementation of nursing interventions
5. Evaluation of outcomes of nursing interventions as they relate to achieving the client’s goals

The client (not the nurse) is at the center of the nursing process, which encompasses health, wellness, and illness in a holistic sense, incorporating all aspects of the client—physical, psychological, social, emotional, cultural, and spiritual. The nurse is uniquely positioned to assess the whole client, administer therapies (including medications), evaluate their effectiveness, and teach the client about how to maintain optimal wellness. The following discussion will focus on the nursing process as it relates to the administration of medications.

Nursing Clinical Judgment

The National Council of State Boards of Nursing (NCSBN) has “developed the NCSBN Clinical Judgment Measurement Model (NCJMM) as a framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination” (NCSBN, 2023, para. 1). Nursing students across the United States are now being tested using the Next Generation National Council Licensure Examination (NGN) model, which was first administered in April 2023. This exam helps to protect the public and measures the minimum competence of a new graduate in regard to safety. Why is this information presented in this text? The nurse must be able to problem-solve and critically think, and the clinical judgment model was developed as a way to test clinical judgment in nursing. Much of a nurse’s clinical judgment revolves around medications and whether a drug is safe to give or recognizing problems.

Clinical judgment is defined by the NCSBN as “the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care” (NCSBN, 2018). An iterative process is one that builds, refines, and improves the process for the best possible outcome.

Safe, efficient care of the client and improved clinical outcomes rely on sound decision-making, clinical reasoning, and clinical nursing judgment. Errors in clinical decision-making often lead to poor outcomes (Nibbelink & Brewer, 2018). According to Sherrill (2020), there are two common errors that novice nurses make that cause them to undergo disciplinary action against their license—a failure to notice and a failure to act. Failure to notice refers to failure on the part of the nurse to see a change in the condition or status of the client. Once a change in the client is observed, it is the nurse’s duty to act in some way to prevent a negative outcome for the client.

The nurse must possess many skills to take care of the client: interpersonal, cognitive, technical, and ethical/legal knowledge (Taylor et al., 2023). The nurse needs to have the technical skill to administer an intravenous push (IVP) medication and subsequently document it in the electronic medical record (eMAR) as well as the ability to determine cognitively that the medication is safe to give. Interpersonal skills are necessary for the interaction between the nurse and the client during the administration of the medication or with the pharmacist and provider when discussing potential problems that might arise from an adverse drug event. Ethical and legal responsibilities are a part of the nurse’s workday each time they chart or encounter an ethical dilemma when deliberating over the risk versus the benefit of a drug. Often this can be seen in the nurse’s role of advocate for the client.

Critical thinking is an essential piece of the nurse’s clinical judgment and is absolutely crucial to the process of administering medications safely. The nurse must think through every decision and action before administering a drug. According to the NCJMM, the nurse must first recognize cues (Dickison et al., 2019). Where is the client located, and how do they present? For example, the client may have presented to a health care clinic in mild distress due to a cough and sinus congestion, or they may have presented to the emergency department with severe shortness of breath and chest pain. What is their history? The nurse should recognize the various signs and symptoms of a disease process and recognize abnormal vital signs and laboratory work, then hypothesize what may be occurring with the client. What is the most important thing for the nurse to assess? Analyzing the cues is important. What is the priority in this situation? How acute are the symptoms? Does immediate action need to occur? The nurse needs to have the underlying knowledge to recognize relationships between signs and symptoms and potential disease processes and likely treatments (including medications). However, the ability to recall nursing knowledge is only part of the nurse’s thinking; the nurse then needs to make the clinical judgments suitable to the situation (Silvestri et al., 2023). What interventions will be most helpful in this situation? Once the nurse intervenes, the question then becomes whether those actions and decisions helped the client.

The nursing process is an integral piece of nursing clinical judgment and embraces the critical thinking process. The nursing process was discussed earlier in this chapter in relation to medication administration. The nursing process can be integrated into the clinical judgment model.

Recognizing cues is the nurse’s skill of observing cues or signs and symptoms of a client’s problem (Dickison et al., 2019). This is accomplished through assessing (the first part of the nursing process). A nurse collects information from many different resources. An example of this might be the nurse who is caring for a client who experienced a myocardial infarction 3 days ago and is to administer metoprolol, a medication that decreases blood pressure and heart rate. The nurse recognizes that those parameters should be assessed prior to giving the drug. Other data will be collected that the nurse then needs to sort through and determine which information is expected and which is unexpected or concerning. The nurse should assess and recognize that the blood pressure of 84/60 mm Hg and the heart rate of 48 beats per minute with the symptoms of dizziness are abnormal.

Analyzing cues is the skill of organizing the information obtained and linking it to the situation (Dickison et al., 2019). Continuing with the previous example, the nurse interprets the data and recognizes that the blood pressure and heart rate are too low to give the metoprolol. A nursing diagnosis or problem list can be formed during this phase based on the assessment data. The nurse requires a knowledge of the pathophysiology of myocardial infarction and knowledge of the therapeutic and adverse effects of metoprolol. The clinical reasoning model uses critical thinking to understand that the nurse recognizes the problem and knows what to do in response to the findings.

The next phase of the process is to prioritize hypotheses (Dickison et al., 2019). This means the nurse will attempt to focus on the meaning of the information that has been obtained and prioritize the client’s problems (Silvestri et al., 2023). What is the priority problem for the client on metoprolol mentioned above? In this example, the client has three problems:

1. Low blood pressure, which may be due to the myocardial infarction or a previous dose of metoprolol
2. Low heart rate due to a previous dose of metoprolol
3. Dizziness due to the abnormal blood pressure and heart rate

The next phase of the process is to generate solutions (Dickison et al., 2019). In this phase, the nurse wants to consider all possible actions that might be utilized to resolve the problem(s). Many times, this includes actions that will be implemented to achieve the desired outcome, but sometimes this will include withholding a medication or recognizing which actions should be avoided (Silvestri et al., 2023). In this instance, the nurse may predict complications of further lowering of the blood pressure and heart rate if the metoprolol is administered. The consequences of administering metoprolol to the client might mean a critical drop in the blood pressure or heart rate, potentially even causing shock.

Dickison et al. (2019) then state that the next phase of this model is taking action. In the example given, the actions the nurse takes during this phase are to withhold the medication, metoprolol, and notify the provider of the problem. This aligns with the implementation phase of the nursing process.

Evaluating outcomes is the last clinical judgment thinking skill in the clinical reasoning model and aligns with evaluating the interventions that the nurse implemented (Silvestri et al., 2023). The nurse must evaluate the outcome of whether the client meets the goal of improved blood pressure and heart rate when the metoprolol is withheld.

These processes are not linear; they are cyclical. The nurse will continue to assess, recognize, analyze, generate solutions, respond by taking action, and reflect on the outcomes. The nurse expects the outcome of the blood pressure and heart rate to return to baseline after holding the metoprolol; however, the nurse must continue to reassess the client to ensure that this occurs and act accordingly. If the blood pressure and/or heart rate do not increase, the nurse must then implement other interventions and evaluate whether they were successful.

This example of clinical judgment actually occurs before administering the drug. A similar process would occur even if the blood pressure and heart rate were normal. Then the process would occur again when the nurse assesses the client for adverse effects.

Principles of Safe Drug Administration

Safety is a fundamental element in the process of medication administration. It is important to demonstrate good clinical decision-making skills throughout the procedure. The focus of the nurse’s clinical judgment during medication administration begins with first knowing the client and assessing the relevant information according to the medications that need to be delivered. Medication reconciliation is performed to ensure that the medications that the provider has ordered are accurate and appropriate for the client. Medication reconciliation is the process of identifying and verifying the most accurate list of medications that a client is taking. This should include the drug name, dosage, frequency, and route for the client. This process should also determine why the client is taking the medication. It should include all over-the-counter medications, vitamins, and supplements. This list is then compared to the provider(s) list. This process should occur at any transition in care (admission, transfer to another unit, discharge, and clinic visit). The nurse should scrutinize the list for duplications, incorrect dosages, and omissions (Agency for Healthcare Research and Quality [AHRQ], 2019). Once a focused physical assessment and laboratory assessment have been completed, the client should be informed about the drugs that have been prescribed. If the nurse is unfamiliar with a drug, it is crucial that they learn about it before administering it. Many resources are available to the nurse for that purpose—drug guides, the pharmacist, drug insert labels, or drug apps on the phone or computer, to name a few.

When planning drug administration, the nurse needs to keep safety foremost in mind. Medication errors are common, preventable errors with far-reaching consequences for the client, the institution, and the nurse. The U.S. Food and Drug Administration (FDA) receives more than 100,000 reports of potential drug errors each year (not all errors are reported to the FDA) (FDA, 2019). Tariq et al. (2023) reported that the cost of caring for individuals who had been the victim of drug errors is over $40 billion each year. A meta-analysis by Panagioti (2019) reported that 1 out of 20 clients may be impacted by a preventable medical error and that as much as 12% of this preventable harm results in death or disability. Of these errors, medication-related errors accounted for the majority. Ethics, Legal Considerations, and Safety discusses medication safety in further depth and emphasizes additional strategies to prevent errors.

Medication safety means ensuring that the right dosage of the right drug is administered to the right client at the right time by the right route or the right reason, and it is documented correctly (the seven rights of medication administration; see Figure 2.2). Nursing practice has expanded the original five rights of medication administration to seven. These rights have been identified as basic standards of care in medication administration in order to preserve client safety. Most institutions require nurses to review these rights at least three times before administering medications. An example of what can happen if all seven rights are not followed might look like this: the nurse has the right dose of the right drug via the right route at the right time for the right reason, but if the nurse walks into the wrong room and fails to identify the right client, a medication error (and potential harm) occurs.

Figure 2.2 Adhering to the seven rights of medication administration will help the nurse administer drugs safely. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The seven rights are:

• Right client (person): The Joint Commission recommends using at least two identifiers to ensure that the nurse administers drugs to the right client. Name, date of birth, and/or medical record number are standard client identification methods. Confirming two identifiers safeguards the client from harm. When possible, request that the client verbalize their name and date of birth while verifying this information by comparing it to the wrist ID band and the client’s chart.
• Right medication: Most institutions have policies in place to ensure that the right client receives the right medication. Medication dispensing systems and barcode scanning are additional processes that many institutions use to assist the nurse during administration. The nurse must compare the medication label or container three separate times—once when obtaining the medication, again when preparing the medication, and finally, and most importantly, when at the bedside. The nurse should also check the expiration date and verify that the medication was stored properly. The nurse should know the action of the medication and how it is to be administered so that all materials can be obtained when drawing up the drug. Allergies and reactions should also be verified to prevent a client from getting a drug to which they are allergic.
  • Barcode scanning: For institutions that use barcode scanning, each drug container (usually a unit dose package such as a blister pack, vial, or prefilled syringe) is labeled with a unique barcode. The information in the barcode allows for the comparison of the medication being administered with what the health care provider ordered for the client before administration. The nurse first signs into the computer or uses the barcode scanner, a handheld device, to scan the barcode on the clinician’s badge. The nurse then uses the scanner to scan the barcode on the client’s unique client identification wristband and the drug. The system then verifies the drug to be given with the order in the system. The clinician is given a warning if the information does not match. Strudwick et al. (2018) report in an integrative review that barcode technology significantly decreases medication errors when proper scanning is completed consistently before administration.
• Right dose: The nurse must validate the right dose and any drug calculations that were performed. They can ask another nurse to validate doses of high-alert (more dangerous) drugs, such as heparin or insulin. The nurse needs to know the usual safe dosage ranges and maximum doses to ensure safe administration and question doses that are outside the usual range or seem unsafe.
• Right time: Each institution has its own policy regarding acceptable time frames for medication administration. Most institutions allow a drug to be given within a time frame of 30–60 minutes before or after the scheduled dose. Drug schedules are important to keep drug concentrations steady. If a drug is given too early, this might result in a drug overdose; however, if it is given too late or omitted, then the client may be undertreated.
• Right route: The nurse must administer the drug via the correct route and verify that the route is safe for that particular client. They should never assume the route of administration—it must be confirmed with the provider if it was omitted from the order.
• Right indication for use (reason): The nurse confirms why the client has been ordered the medication; for example, beta-adrenergic blockers may be administered for angina, hypertension, myocardial infarction, dysrhythmias, or heart failure. Knowing why the medication has been ordered will assist the nurse in assessing the drug’s therapeutic effect. They should clarify orders that do not seem appropriate for the client.
• Right documentation: The nurse needs to ensure that documentation is completed after the drug has been administered. They should not document medication administration prior to giving the drug. If there was any variance in the drug administered, the nurse needs to ensure that the reason is documented. The nurse also should document if the client refuses the drug and why, as well as if a medication was withheld and the explanation for holding it.

Nurses should encourage clients to participate in their care by questioning the nurse about the medications being delivered. Collaboration with other health care providers will also assist in keeping the client safe during medication administration. In the inpatient setting, the verified medications are withdrawn from the medication dispensing machine, the materials needed to administer the drugs are obtained, and all are taken to the client. The medication should remain in the original container until the nurse is at the bedside, ready to administer the medication. The nurse identifies the client, using two unique client identifiers, and the drug is reverified as the correct drug before giving to the client. The medication can be reverified by checking the drug label with the medication administration record or through the use of barcode scanning, where available, at the bedside prior to administering the medication. The nurse follows medication administration by planning on when to reevaluate the client for therapeutic response and adverse effects.

Client Education and Drug Administration

One important responsibility that a nurse has is client education. According to the American Nurses Association (2021), teaching and promoting health and wellness is expected of the nurse providing care to a client. Teaching is about using specific strategies to reinforce or change specific behaviors. Learning is the desired outcome that results from teaching. A change in behavior is the evidence of teaching and learning. The primary target for teaching in the health care setting is the client and family or caregiver. In order for the nurse to be an effective teacher, it is important to understand how individuals learn. There are three domains of learning: cognitive, psychomotor, and affective.