The four phases of the nursing process are discussed as
they relate to health teaching with medication therapy.
The assessment phase gathers
the data that will be the basis of the health teaching plan. This includes subjective and objective data.
Subjective data give the nurse
an overview of the past and current health history, the current client medication plan, and the client’s knowledge and perception of the effectiveness of the current plan. The data must include all over-the-counter, or OTC, medications; herbal remedies; street drugs; alcohol; and tobacco used.
It is important for the nurse to note all
allergies to medications and all food and dye intolerance and reactions.
The nurse must also gather information on
the client’s learning style preferences, readiness to learn, mental status, financial status, and primary language.
Objective data are gathered with
a physical health assessment. this includes any client limitations that could interfere with medication self-administration. Diagnostic and laboratory testing focus on those body systems that will be, or are affected by, current and future medication therapy.
The assessment data helps
identify clients at high risk for adverse reactions and noncompliance with medication therapy.
Analysis of the assessment data assists the nurse in
making nursing diagnoses, both actual and potential. These nursing diagnoses help guide the rest of the plan of care.
The planning phase of the nursing process focuses on
working with the patient to set goals or expected outcomes. After the goals are created, the nurse develops nursing interventions designed to help the client meet the goals. Effective goals are client centered, acceptable to the client and nurse, measurable, and realistic. These goals are shared with the health care team.
Client education regarding the medication regimen is a key piece of
the implementation phase of the plan. Also included in this phase are administration of medications and assessment of medication effectiveness.
In preparing the education plan for the client, the nurse uses assessment data to
suggest the number and complexity of the educational sessions and the client’s motivation and readiness to learn.
The nurse must keep in mind that the information should be
tailored to the client’s interest and level of understanding.
It might be helpful for the nurse to have
an outline of the planned teaching points.
It may help with the education of the client to include
a family member or friend involved in the care of the client.
The client should be given appropriate
contact information for the nurse or health care provider for questions and concerns.
It is also important for the nurse to be
culturally sensitive while providing teaching to the client. This sensitivity includes any cultural expectations imposed on the client and any communication behaviors that are acceptable within the client’s culture.
A teaching plan with interventions that stimulate several senses and active participation by the client helps
enhance learning. Return demonstrations by the client and others involved in the client’s care provide client confidence.
The evaluation phase of the plan is ongoing, and it
documents attainment of the final goal. If a client goal is not met, the nurse returns to the assessment phase and establishes new goals and interventions as necessary.