NURSING PROCESS: PATIENT-CENTERED COLLABORATIVE CARE

ASSESSMENT
The assessment phase of the nursing process is characterized by the systematic validation and
documentation of information. Assessments are made throughout the nursing process. Assessment is particularly
important because the data provided by the assessment form the basis on which nursing diagnoses are made and
care is planned, implemented, and evaluated. Data collection must include both subjective and objective information.

Subjective Data
Subjective data are symptoms described by and apparent to the patient. The following components
are reflective of subjective data related to the medication regimen:
 Current health history, including any problems with swallowing
 Patient symptoms
 Current medications, including over-the-counter (OTC) drugs, herbal remedies, and nutritional
supplements
o Dosage, frequency, and route of all drugs, and prescribing health care provider, if any
o Patient knowledge about drug, its side effects, and reason drug is taken
o Patient adherence with regimen and reasons for deviations (Were prescriptions filled and
finished? Are deviations based on valid data/rationale and clinically sound?)
o Patient expectation and perception of drug effectiveness
o Patient knowledge about what effects or drug reactions to report to health care provider
o Drug allergies or reactions both past and present; also reactions to food and dye
o Use of tobacco products, alcohol, caffeine, and recreational drugs, including frequency and
duration of use
 Past health history
o Past illnesses, major injuries, drug therapy
o Mental status
o Medications saved from previous use, reason for saving them, and expiration date
 Patient’s environment
o Home safety (stairs, lighting, rugs, smoke detectors, supplies) and neighborhood safety
(lighting, sidewalks) to meet patient’s and family’s specific needs.
o Patient’s language and communication needs (including language of origin)
o Patient’s ability and readiness to read and follow instructions from the health care provider
and the pharmacy
o Patient knowledge of specific drug storage requirements, if any
o Availability, willingness, and psychomotor ability to administer or assist in the administration of
medications; capability for activities of daily living (This information is essential for third-party
payment for continued home visits or for admission to an extended care facility.)
o Household members (neighbors and friends and their roles, if possible); ages of household
members
o Learning style preferences
o Readiness to learn
o Dietary patterns, cultural and economic influences, safety
o Financial resources or limitations (drugs can be expensive)

Remember:
Patients, even those who do not intend to withhold information, do not always share everything about
their medications. Therefore, in addition to asking about prescription drugs, ask specifically about vitamin and
mineral supplements, herbal supplements, all contraceptives, and OTC drugs.
Identify caffeine and nicotine use, and include questions about use of skin patches; laypersons often
fail to see patches as a mechanism of drug administration. Home health nurses should ask to see the
contents of the medicine chest at home (or other storage area for medications) and should ask if the patient
practices pill-splitting as a cost-saving measure and whether a pharmacist is consulted. Based on the
response, appropriate teaching can be initiated.

Objective Data
Objective data are signs that are measured and detected by another person. The following
components are reflective of objective data related to the medication regimen:
 Physical health assessment: Limitations in gross- and fine-motor control; hand and joint range of
motion; hand and finger muscle strength; visual impairment; and ability to read labels and correctly
measure dosages.
 Laboratory test results and diagnostic studies: Baseline data are essential for future comparisons.
 Data collection should provide additional information about the patient’s symptoms and should also
target those organs most likely to be affected by drug therapy. For example, if a drug is nephrotoxic, the
patient’s creatinine clearance should be assessed. Assess major body systems for any signs of reaction to or
interaction of drugs or ineffectiveness of therapy.

Based on assessment data, the nurse must identify high-risk patients (those likely to have adverse
reactions). The patient’s health history, physical assessment, and laboratory test results are sources of these
data.

Enhancing patient adherence with the drug therapy regimen is an essential component of health teaching.
The patient and family response to the following three questions provides the nurse with critical information
unique to each patient’s teaching situation:
1. What things help you take your medicine as prescribed?
2. What things prevent you from taking your medicine as prescribed?
3. What would you do if you forgot to take a dose of medication?

Frequently cited factors for non-adherence include forgetfulness, knowledge deficit, side effects, low self-
esteem, depression, lack of trust in the health care system, family problems, language barriers, high cost of
medications, anxiety, value systems (e.g., religion), and lack of motivation. Drug shortages create additional
concerns because patients may be dissatisfied with the effectiveness, cost, and side effects of alternative
drug choices.

The patient’s attitudes and values about taking medication are very important considerations when
determining the patient’s and family’s readiness to learn. These attitudes and values should be considered
when planning interventions to support the patient’s decision to adopt healthy behaviors related to taking
medications. The patient’s social support system is emphasized. This special support system, unique to the
individual, may be composed of persons who assist in preparing medications, organizing pills, and ordering
medications, and can be alert to side effects—all actions that promote taking medication as prescribed and
notifying the health care provider if a problem arises.

NURSING DIAGNOSIS
A nursing diagnosis is made based on the analysis of the assessment data. Abnormal data collected during
the assessment serve as the defining characteristics (for an actual problem) or risk factors (for a high risk for a
problem) to support the appropriate nursing diagnosis. More than one applicable nursing diagnosis may be generated.
The registered nurse formulates nursing diagnoses and uses them to guide the development of a care plan.

Common nursing diagnoses related to drug therapy include the following:

 Pain (acute or chronic) related to hesitancy in taking prescribed pain medications because of fear of addiction
 Acute confusion related to adverse reaction to medication
 Ineffective health maintenance related to not receiving recommended preventive care
 Deficient knowledge related to effects of anticoagulant medication on clotting mechanism
 Noncompliance related to forgetfulness
 Risk for injury related to side effects of drug (e.g., dizziness, drowsiness)
 Ineffective self-health management related to lack of finances or health care coverage to purchase
medications
 Readiness for enhanced knowledge related to medication schedule and medication side effects

Use of these nursing diagnoses is beneficial to the patient because it facilitates the development of an individualized
care plan for each patient. Note: To strengthen comprehensiveness of nursing diagnoses, consider using well/health
promotion diagnoses.

PLANNING
The planning phase of the nursing process is characterized by goal setting or expected outcomes. Goals
are patient centered, describe the specific activity, and include a time frame for achievement/reevaluation. Planning
also includes development of nursing interventions that will be used to assist the patient to meet the goals. Effective
goal setting has the following qualities:
 Is patient centered (accomplished through collaboration with the patient and/or family to develop goals that
focus on patient outcomes)
 Clearly states the expected change: realistic, measurable, with reasonable deadlines
 Is acceptable to both patient and nurse (dependent on patient’s decision-making ability)
 Is shared with other health care providers and with patient’s family or caregiver
 Identifies components for evaluation
Examples of well-written comprehensive goals are (1) patient will independently administer prescribed dose of insulin
by end of the fourth session of instruction; (2) patient will prepare a medication recording sheet that correctly reflects
prescribed medication schedule within 3 days.

IMPLEMENTATION AND NURSING INTERVENTIONS

The implementation phase is the part of the nursing process in which the nurse provides education,
medication administration, patient care, and other interventions necessary to assist the patient in accomplishing the
established goals. In most practice settings, administration of drugs and assessment of drug effectiveness are also
important nursing responsibilities.

Patient Teaching
Readiness to learn is paramount. Patient education is an ongoing, complex, multifaceted process and
a dynamic interaction between nurse and patient in which both communicate information and emotions.
Teaching is focused on health promotion and/or a specific skill to optimize patient health status. Teaching is
more effective in an environment free of distractions, and the information should be tailored to the patient’s
interests and level of understanding. Assessment data suggest the complexity, number, and length of
teaching sessions that may be required. Be sensitive to the patient’s motivation to learn, attention span, and
level of frustration. Readiness to learn is paramount. Readiness should be assessed first, before information
is presented to the patient. Use a positive approach—for example, “This narcotic is usually effective for the
relief of the type of pain you have.” Be an active listener and observer.

Assessment data guide the nurse to the appropriate persons to be included. The inclusion of a family member
or friend in the teaching plan is an excellent idea. This person may (1) act as a psychological support, (2)
actually administer all or part of the drug therapy, (3) observe the effectiveness and side effects of the drug
therapy, and (4) implement other changes such as food shopping or instituting new methods of food
preparation. Provide simple written materials appropriate for individual patient needs. The patient and family
must have the appropriate information (e.g., telephone number, email address) to reach the health care
provider for questions and concerns. Health care providers should be available to provide timely responses.

With patient teaching being critical to the success of pharmacotherapy, it might be helpful for the nurse to use
an outline format for patient education. Suggested topics related to pharmacotherapeutics include the
following:
 General. Instruct the patient to take the drug as prescribed. Adherence is of utmost importance
because discontinuing the drug before the course is completed may result in relapse or future
ineffectiveness of the drug. Do not adjust dose, frequency, or time of day taken unless directed by the
health care provider. Advise women contemplating pregnancy to check first with their health care
provider before taking prescription or OTC medications and herbal products. Advise patients to
consult with their health care provider about laboratory tests such as liver enzymes, blood urea
nitrogen (BUN), creatinine, and electrolytes, which should be monitored when taking selected drugs.
 Self-administration. The patient’s psychomotor skills and abilities are critical. Based on assessment
of these, consider recommendations for modifications as appropriate. Reassess psychomotor skills
on an ongoing basis. Instruct the patient on the administration of the drug according to the prescribed
route: eye-drops or nose-drops, subcutaneous insulin injections, suppositories, swish-and-swallow
suspensions, and metered-dose inhalers with and without spacers. Include demonstration and return
demonstration in the instructions when appropriate. Give written instructions for the sighted patient
and audio instructions for the visually impaired. Teach more than one person when possible, because
this aids in reinforcement and retention of information. It also provides a “backup” if the patient is
unable to self-administer the drug.
 Diet. Advise patients about foods to include in their diet and foods to avoid. Many foods interact with
certain drugs. Depending on the nature of the interaction, certain foods have the ability to decrease
drug absorption, increase the risk of drug toxicity, or create other problems that make them an
important safety concern.
 Side effects. Instruct the patient to report unusual symptoms immediately to the designated health
care provider—usually a nurse, physician, or pharmacist. Give the patient instructions that help
minimize any side effects (e.g., avoiding direct sunlight when there is risk of photosensitivity or
sunburn). Advise the patient of any expected changes in the color of urine or stool. Advise the patient
who has dizziness caused by orthostatic hypotension to rise slowly from a sitting to a standing
position.
 Cultural considerations. A culturally sensitive nurse is one who has an awareness of the
implications of culture for the patient and family. Be alert to patient and family cultural expectations.
For example, the patient may not view time as important, which may affect the patient’s adherence to
taking medications at specific times during the day. The nurse applies knowledge of cultural
considerations to individualize a teaching plan.
 CULTURALLY SENSITIVE HEALTH TEACHING TIPS
 Flexibility in timing appointments may be necessary for those who have a circular sense of time
rather than a linear sense of time.
 The nurse should consider whether appointments are something deemed culturally relevant.
 Discuss the ethnicity of the interpreter as well as the language desired when translation is needed.
Provide an interpreter with the same ethnic background and gender if possible, especially with
sensitive topics. Speak clearly and slowly, giving time for translation. Ask family members to assist
with translation only if an interpreter is not available.
 Use videos and literature in the patient’s preferred language to enhance adherence to health
interventions when language and cultural barriers exist.
 Use simple and clear instructions that employ user-friendly terminology at the fourth-grade level.
Avoid use of acronyms and abbreviations. Allow adequate time for information processing; failure to
do this may result in an inaccurate response or no response. Allow time response to questions,
especially for patients who have language barriers.
 Ask open-ended questions, and have patients demonstrate, rather than verbalize, their
understanding of treatments. Because politeness and “saving face” may be important, do not
assume that a positive response means a definite yes.

A teaching plan with interventions that involves stimulation of several senses and active participation by the
patient enhances learning. Inclusion of return demonstrations by the patient and others, when applicable,
gives the nurse important feedback about the patient’s learning and gives the patient confidence in carrying
out the regimen or selected aspects of the regimen. Additional teaching tips include the following:
 Establish a trusting relationship.
 Teach patient and family the importance of bringing a medication list (including OTC, herbal, and
vitamin products) or medications to all health care provider appointments in all settings.
 Provide written instructions in addition to other teaching aids.
 Use colorful charts and graphs.
 Consider using a variety of media, including audio and video.
 Encourage questions from patient and family; provide time for this. Do not rush.
 Use materials and language appropriate to patient’s level of understanding; supply patient medication
information sheets in different languages and appropriate reading levels.
 Space instruction over several sessions, if appropriate.
 Review community resources related to patient’s nursing and medical diagnoses.
 Collaborate with patient and family and other health care staff and agencies to mobilize resources to
meet patient’s needs.
 Identify patients at risk for noncompliance with regimen. Alert health care provider and pharmacist so
they can develop a plan to minimize the number of drugs and times administered.
 Evaluate patient’s understanding of medication regimen on a regular basis.
 Empower patient to take responsibility for managing medications.

The use of teaching drug cards is helpful. These cards provide information about a specific drug or drug
group. They may be developed by the health care provider or obtained from drug manufacturers. Helpful
components for the teaching drug cards include name of the drug; reason for taking the drug; dosage; specific
times to take the drug; possible side effects; possible adverse effects and when to notify health care provider;
and specific things that should or should not be done while taking the medication (e.g., do not crush, take with
food).

POINTS FOR PATIENTS AND FAMILIES TO REMEMBER

 Take medication as prescribed by your health care provider. If you have questions, call.
 Keep medication in the original labeled container, and store as instructed.
 Keep all medicines out of the reach of children. Remind grandparents and visitors to monitor their
purses and luggage when visiting.
 Before using any over-the-counter (OTC) drugs, check with your health care provider. This includes
use of aspirin and laxatives. Consider asking the pharmacist before buying or using a product.
 Bring all medications with you when you visit the health care provider.
 Know the purpose of each medication and under what circumstances to notify the health care
provider.
 Do not drink alcoholic beverages around the time you take your medications. Alcohol is absolutely
contraindicated with certain medications. Alcohol may alter the action and absorption of medications.
 Be aware that smoking tobacco also alters the absorption of some medications (e.g., theophylline-
type drugs, antidepressants, pain medications). Consult your health care provider or pharmacist for
specific information.
 Many people take multiple medications simultaneously several times each day, which presents a challenge to
the patient, his or her family, and the nurse. This complex activity of taking medications can be segmented
into several simple tasks, including the following:
 Preparation of 1 day’s or 1 week’s supply of medication. The day’s medication can be put into one
container. Sorting of a day’s supply allows the patient and the nurse to see at a glance what
medications have and have not been taken. Keep in mind that a missing pill may have been dropped
and not actually taken. A variation in accomplishing this task is to take a day’s medication and sort or
package the pills according to the time each is to be taken. Multi-compartment dispensers (available
at drugstores) or an egg carton may help some patients sort their drugs.
 A recording sheet may be helpful. The patient or a family member marks when each medication is
taken. The sheet is designed to meet the patient’s individual needs; for example, the time can be
noted by the patient or can be entered beforehand, with the patient marking when each dose is taken.
A generic format follows.

Dosage Day of Week

Medication (mg Daily) S M T W Th F S
captopril (Capoten) 12.5
digoxin 0.25
furosemide (Lasix) 40

Alternatives to recording sheets are also available. Alarm reminder devices may be helpful to some patients.
A combination of daily supply and recording may be helpful. Consider color-coding. Visual acuity, manual
dexterity, and mental processes have a major effect on which system works best for each patient.

Throughout the teaching plan, the nurse promotes patient independence (e.g., self-administering medications,
safely storing medications, ordering medications).The nurse should not lose sight of the goals or outcomes
and become immersed in the intervention process (e.g., teaching a patient with short-term memory loss).

CHECKLIST FOR HEALTH TEACHING IN DRUG THERAPY

 Comprehensive drug use and health history
 Reason for medication therapy
 Expected results
 Side effects and adverse reactions
 When to notify health care provider or pharmacist
 Drug-drug, drug-food, drug-laboratory, and drug-environment interactions
 Required changes in activities of daily living (ADLs)
 Demonstration of learning; may take several forms, such as listening, discussing, or return
demonstration of psychomotor skills (insulin administration)
 Medication schedule, associated with ADLs and drug level of action as appropriate
 Recording system
 Discussion and monitoring of access to financial resources, medication, and associated equipment
 Development and support of backup system
 Community resources available

EVALUATION
In the evaluation phase of the nursing process, the nurse determines how well goals are obtained. Nursing
interventions are revised and teaching is focused to improve goal attainment if goals are not met.

The specific outcomes must be articulated with the patient and significant others to determine if they have been met.
Additional data may be needed to assess if adherence to the drug regimen is not done. For example, patients may be
denying or minimizing their diagnosis, financial problems may prevent timely prescription refill, or vision or physical
limitations may inhibit administration of the drug. When the evaluation of a goal will occur depends on the time frame
specified in the statement of the goal. Evaluation should be ongoing and related to progress as well as to attainment
of the final goal.

If goals are not met, the nurse, in collaboration with the patient or family, must determine the reasons and revise the
plan accordingly. This includes additional assessment data and the setting of new goals.

To complete the care for any current patient, review with the patient and family the need for follow-up care, if required,
and refer the patient to community resources as necessary.
Reference:
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2015). Pharmacology: A Patient-Centered Nursing Process Approach. In J.
L. Kee, E. R. Hayes, & L. E. McCuistion, Pharmacology: A Patient-Centered Nursing Process Approach (pp. 114
- 118). Missouri: Elsevier Inc.