Relating Nursing Diagnoses To Drug Therapy

How to develop better care plans by applying nursing diagnoses to problems with your patients' drug therapy. BY MEREDITH A N N McCORD, RN. MS Assistant Professor • Oregon Health Sciences University • School of Nursing •ftjrtland.Oregon

ursing diagnoses help you identify patient problems and establish priorities of care. Among the most common diagnostic labels used by nurses to develop care plans for the management of a patient's drug regimen are "knowledge deficit" and "noncompliancc." You may also identify other nursing diagnoses, depending upon the potential risks or adverse effects occurring secondary to drug therapy. Consider how you might use these diagnoses with your patients. Knowledge deficit A knowledge deficit can occur for various reasons, depending on the etiologies and defining characteristics you identify. For example, defining characteristics for a knowledge deficit might include: • statement of misconception • verbalization of the problem • request for information Adapted from the if w pharmacutoKy textbook Clinical Pharmacology and Nursing bvCiaroUL.Saer, RN, PhD, and Bradley R. Williams, PharmD. D I9SS Springhouse Corp.. Springhouse. Pa.

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• inaccurate follow-through of instruction • inadequate test performance • inappropriate or exaggerated behaviors. Your diagnosis depends upon the assesstnent data on and drug regimen for each patient. The following case illustrates how a knowledge deficit can result from several causes. Mrs. Kaminsky. age 71. entered the hospital with shortness of breath and difficulty walking because of edema and pain in her legs. She was diagnosed as having congestive heart failure and was started on the following medications: digoxin 0.25 mg P.O. daily, furosemide (frusemide, Lasix) 40 mg P.O. daily, and potassium chloride (K-Tab) 2 tablets P.O. twice a day. Mrs. Kaminsky*s only significant medical history is a 2-year history of hypertension, which is being monitored by her family internist. Mrs. Kaminsky takes no other drugs except for a calcium supplement and daily vitamins. At this time, she can perform her routine daily activities without shortness of breath. Her legs remain slightly

swollen, though greatly decreased in size from the time of admission, and her weight remains 3 pounds above her expected dry weight. She is to be discharged in about 3 days if no complications arise. Mrs, Kaminsky lives alone, although her son and his family live nearby. She wants to return to her home and asks questions regarding her drugs, diet, disease, and activity levels. In Mrs. Kaminsky's case, you may be dealing with a "knowledge deficit, related to the new drug regimen." a "knowledge deficit, related to the prescribed diet." or a "knowledge deficit, related to the self-management of congestive heart failure" diagnosis, Noncompliance Noncompliance is another diagnostic label that can occur when you deal with a patient and a specified drug regimen. Some defining characteristics of noncompliance include: • behavior indicating failure to follow a regimen, supported by direct observation or statement by the patient or significant other

• failure on objective tests • evidence of the development of complications • exacerbations of the symptoms • failure to keep appointments • failure to progress • inability to set or maintain mutual goals. The following example illustrates some of the identifying characteristics of noncompliance; Mr. Miller, age 65. is admitted to the hospital with an exacerbation of his emphysema. Within the past 12 months. Mr. Miller has entered the hospital three times with the same medical diagnosis. Each time, he received intravenous antibiotics, steroids, and oxygen. During Mr, Miller's present admission, you note the following characteristics as part of the assessment, "The patient is alert, exhibits circumoral cyanosis, has a respiratory rate of 32 with the use of accessory muscles, has breath sounds with scattered insptratory and expiratory wheezes throughout and crackles in the posterior bases, has a cough productive of thick yellowgreen secretions, and states his short-

ness of breath has increased over the past 2 weeks, until he now needs assistance to perform his daily activities. The patient has a 50 pack-year history of smoking; he smokes one pack per day and has refused to decrease this. He states that he quit taking his drugs 2 weeks before admission because they did not seem to make any difference in how he felt and were expensive. Upon further discussion. Mr. Miller could not state the effects of his drugs and treatments," Mr. Miller lives with his wife, who also has several medical problems that require treatment. He is on a fixed income; he has insurance, the benefits of which are almost exhausted; Medicare: and Social Security, During the present admission, the patient's respiratory status has improved. He performs his regular activities with minimal shortness of breath, although he needs oxygen at night. Upon discharge, he is to take prednisone 40 mg RO,. which should be tapered over the next 2 weeks according to a set schedule, theophylline (Theo-Dur). metaproterenol {Alupent Inhaler), beclomethasone (Vancenase Nursing88, October

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Inhaler), Lasix. potassium chloride (K-Lor), and cephalexin (Keflex) for 10 days, and use oxygen at night. The defining characteristics for Mr. Miller include his repeated admissions for the exacerbation of emphysema; discontinuance of treatment; questionable understanding of the prescribed treatment; minimal resources to pay for treatment; and your assessment findings, including shortness of breath, wheezes and crackles, the use of accessory muscles for breathing, and an increased respiratory rate. You need to collect more information about Mr. Miller's disease knowledge and his beliefs about the effects of the treatment. You may be dealing with "noncompliance, related to a misunderstanding of the importance of the prescribed drug regimen" or "noncompliance, related to a lack of financial resources." Other diagnostic iabels For alteration in health maintenance, another commonly used diagnostic label, the identified defining characteristics include: • a demonstrated lack of knowledge about basic health practices • a demonstrated lack of adaptive be-

haviors to internal or external environmental changes • a reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas • a history of lacking health-seeking behavior • an expressed interest in improving health behaviors • a reported or observed lack of equipment or financial resources or other resources • a reported or observed impairment of personal support systems. Possible nursing diagnoses related to "alteration in health maintenance" may resemble the following: "alteration in health maintenance, related to the pa-^ tient's inability to comprehend the established drug regimen," "alteration in health maintenance, related to paralysis of the patient's right side," and "alteration in health maintenance, related to a cognitive inability to manage the prescribed drug regimen." You may formulate and use many other nursing diagnoses, depending upon the potential or actual adverse effects of drug regimens. The North American Nursing Diagnosis Association has ap-

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proved 98 diagnostic labels, from which these have been developed; • potential for injury, related to anticoagulant therapy • alteration in skin integrity, related to a reaction to the prescribed medication • alteration in oral mucous membranes, related to a superimposed infection (which could be from steroids, chemotherapy, or antibiotic use) • alteration in nutrition; less than body requirements, related to nausea, anorexia, and chemotherapy • sexual dysfunction, related to prescribed medications (such as propranolol llnderall). With such nursing diagnoses, the defining characteristics will depend upon the patient's specific reaction to the particular drug regimen. For example, with the diagnosis "potential for injury, related to anticoagulant therapy," the defining characteristics may include the presence of petechiae, increased bruising, an elevated prothrombin time above therapeutic levels, or the use of aspirin. For the diagnosis concerning "alteration in nutrition," the defining characteristics may include decreased weight, eating less than 50% of meals, weakness, or

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a change in the way foods taste. Once the nursing diagnosis is formulated, you can proceed to the planning step of the nursing process, determining the nursing plan of care for the patient. This consists of two major components: the outcome criteria (or patient goals) and nursing interventions. Developing outcome criteria The outcome criteria, the first critical component of the nursing plan of care, represent patient goals and include the desired patient behaviors or responses that should result from the nursing care. Outcome criteria should exhibit certain characteristics. First, each outcome criterion should be expressed as a measurable and objective statement that can be answered with yes or no. For example. '"The patient verbalizes the major adverse effects related to his chemotherapy drugs before discharge" or "The patient demonstrates the proper administration of her antibiotic regimen before discharge."' Next, outcome criteria should be realistic for each patient. You can't realistically or appropriately expect a patient with a chronic respiratory dis-

order to have a PaO, in the 80s. although a PaO; in the 50s could be acceptable. Use only one behavior for each outcome criterion, thereby reducing the chance of ambiguity and clarifying the patient goal for other nurses as well as for the patient. For example, the outcome criterion "The patient lists and demonstrates the steps necessary to use the Alupent Inhaler" contains two behaviors. The patient may be able to list but not demonstrate the necessary steps for using the inhaler, thus producing ambiguity about whether the patient has met the goal. The statement should be written as two criteria: "The patient lists the steps necessary for using the Alupent Inhaler" and "The patient demonstrates the steps necessary for using the Alupent Inhaler." You can further clarify by being as concise as possible. When developing a care plan, express the outcome criteria in terms of patient expectations. For example, "Cephalothin (Keflin) 2 grams will be given q 6 hours" or "The patient will be turned q 2 hours" represent nursing interventions, not patient goals or outcome criteria. Remember, an outcome criterion states

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what you want the patient to achieve after the nursing care. In the first intervention about the Keflin administration, a possible outcome criterion may be; "Patient will be free of infectioti in left leg ulcer" or "Patient verbalizes the proper sequence for Keflin administration." In the intervention about turning the patient, a possible outcome criterion may be written as "patient is free of any redness over bony prominences." Finally, each outcome criterion should be attainable by nursing management, within a designated time frame, sueh as "by the time of discharge" or "after the initial teaching session." When writing outcome criteria, you must consider four major components: the content area, an action verb, a time frame, and criterion modifiers. For an explanation of the components, along with examples, see Writing Outcome Criteria. A word of caution: You may use all of the correct components when forming an outcome criterion yet fail to write a meaningful statement. For example, "The patient will develop critical thinking in relation to the emer-

WRITING OUTCOME CRITERIA The essential components of outcome criteria and examples of those components are: CONTENT AREA Describes the subject that the patient will focus on or the response to be eiicitedt such as • action of digoxin • pulse taking ACTION VERB Describes how the patient will achieve the content area aim, such as • verbalize the action of digoxin • demonstrate pulse taking TIME FRAME Gives a target date for completion of the outcome criteria, such as • verbalize the action of digoxin after the initial teaching session • demonstrate pulse taking by discharge CRITERION MODIFIERS Add specificity to the subject, action, or time, such as • verbalize correctly the major action of digoxin after the initial teaching session • demonstrate pulse taking before discharge with a degree of accuracy within four beats of the pulse the nurse takes

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gency procedures to follow when adverse effects of the chemotherapy occur at home.'" The statement looks and sounds impressive, yet no nurse could accurately measure "develop critical thinking." Remember, each outcome criterion should represent a concise statement that calls for one objective, measurable patient behavior or response. Nursing interventions After developing the outcome criteria, you determine the interventions needed to help the patient reach the desired behavior or response goals. Interventions are the actions that you and other nurses implement to meet the identified outcome criteria. The types of interventions and strategies depend upon the identified nursing diagnosis and outcome criteria. If the nursing diagnosis states "knowledge deficit, related to newly prescribed Lasix."" you may focus interventions on patient education for the actions, adverse effects, and scheduling of Lasix as well as the monitoring of daily weights. If the diagnosis states "knowledge deficit, related to the administration of daily insulin."" you might develop interventions that

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focus on education for ihe action and adverse effects of insuiin. steps to take in case of an insulin reaction, demonstration of self-injection techniques. and observation and guidance for the patient when administering selfinjections. Remember, the type of strategies or interventions depend upon the established nursing diagnosis, outcome cri-

teria, and the individual patient. (See 7110 Nursing Care Plans for examples that illustrate the progression from diagnosis to outcome criteria to intervention.) By carefully developing a nursing care plan based on these components, you can work toward successful management of your patient's drug therapy and completion of the nursing process.

TWO NURSING CARE PLANS These two examples show how you might develop nursing care plans for managing patient problems related to drug therapy. NURSING DIAGNOSIS Kriowledge deficit, related to the new drug regimen (includes digoxin, furosemide [frusemide, Lasix], and potassium chloride [K-Tab])

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OUTCOME CRITERIA Before discharge, Mrs. Kamjnsky will: • Stale the ma|or action of each drug • Idenfify at least three adverse reactions that should be brought to the immediate attention of a health care practitioner • Describe the importance of monitoring daily weight. • Demonstrate the ability to take her pulse accurately.

NURSING INTERVENTIONS • Instruct Mrs Kaminsky in the major actions of and possible adverse reactions to each drug. • Instruct Mrs. Kaminsky about adverse reactions that need immediate medical attention, such as a sudden change in weight, nausea, loss of appetite, change in affect, palpitations, or lethargy • Provide Mrs. Kaminsky with a list of adverse reactions for home use. • Discuss the importance of monitoring daily weight and noting more than a 2- to 3-pound increase. • Provide Mrs Kaminsky with written instructions concerning the major actions and adverse effects of each drug as a guide for home use • Include Mrs. Kaminsky's son or significant other in the teaching if possible. • Instruct Mrs Kaminsky on methods for taking her pulse, using demonstration and practice.

NURSING DIAGNOSIS Noncompliance. related to a misunderstanding of the importance of the prescribed drug regimen (includes theophylline [Theo-Dur], metaproterenol [Alupent Inhaler], beclomethasone [Vancenase Inhaler], furosemide ffrusemide, Lasix], potassium chloride [K-Lor], and cephalexin [Keflex]) OUTCOME CRITERIA By discharge, Mr. Miller will: • State two reasons why he has exacerbations of his emphysema • Identify at least three signs that may indicate exacerbations ot his emphysema. • Verbalize the major actions of the prescribed drugs. • Describe the difference between adverse reactions to the drugs and the signs of exacerbations of his emphysema. • Describe the relationship between his drug regimen and his emphysema. • Verbalize the importance of taking his prescribed drugs as ordered

NURSING INTERVENTIONS • Discuss emphysema with Mr. Miller, noting the disease process and why exacerbations occur— discontinuation of his drugs, progression of his disease or exposure to cold viruses. • Instruct Mr Miller about the signs and symptoms that indicated a need for medical attention before hospitalization and how to monitor the signs, including increased shortness of breath, increased use of oxygen, inability to perform activities of daily living, and changes in the color of secretions. • Discuss and provide written information on the drug actions. • Discuss the relationship of the prescribed drugs to his disease • Discuss the difference between the adverse reactions to the drugs and signs and symptoms that indicate an exacerbation of his emphysema or progression of the disease state. Provide Mr. Miller with a list of the information • Contact the home health agency tor follow-up care. • Involve Mr. Miller's wife in the teaching sessions. • Contact social services to assess the family finances, and refer Mr Miller to hospital and community resources.