Nursing Process: Assessment

Question 1

History

Answer 1

Before you administer medications, review a patient’s medical history to
help you understand the indications or contraindications for medication
therapy. Some illnesses place patients at risk for adverse medication
effects. For example, if a patient has a gastric ulcer, medications containing
aspirin increase the likelihood of bleeding. Long-term health problems
(e.g., diabetes or arthritis) require specific medications.

Question 2

Allergies

Answer 2

Inform the other members of the health care team if a patient has a history
of allergies to medications and foods. Many medications have ingredients
also found in food sources. For example, propofol, which is used for
anesthesia and sedation, includes egg lecithin and soybean oil as inactive
ingredients. Therefore, patients who have an egg or soy allergy should not
receive propofol (Skidmore-Roth, 2018). In most health care se􀄴ings
patients wear identification bands listing medication and food allergies.
Ensure that all your patient’s allergies and their allergic reactions are
documented appropriately in the patient’s medical record (e.g., history
and physical, MAR) to facilitate communication of this essential
information to members of the health care team.

Question 3

Medications

Answer 3

Ask your patients questions to find out about each medication they take
(Box 31.7). Possible questions include: How long have you been taking
these medications? What is the current dosage of each medication? Do you
experience side effects or adverse effects from your medications? In
addition, review the action, purpose, normal dosage, routes, side effects,
and nursing implications for administering and monitoring each
medication. You often need to consult several resources such as
pharmacology textbooks; medication manuals available on a computer,
electronic tablet, or AMDS; nursing journals; the Physicians’ Desk Reference
(PDR); medication package inserts; and pharmacists to gather necessary
information. As a nurse you are responsible for knowing as much as
possible about each medication your patients take.

Question 4

Diet History

Answer 4

A diet history reveals a patient’s normal eating pa􀄴erns and food
preferences. Use your patient’s diet history to plan an effective and
individualized medication dosage schedule. Teach your patient to avoid
foods that interact with medications. In addition, provide education when
your patients take medications that need to be taken before, with, or after
meals.

Question 5

Patient’s Perceptual or Coordination Problems

Answer 5

Patients with perceptual, fine-motor, or coordination limitations often
have difficulty self-administering medications. For example, a patient who
takes insulin to manage blood glucose and has arthritis has difficulty
manipulating a syringe. Assess the patient’s ability to prepare doses and
take medications correctly. If a patient is unable to self-administer
medications, assess whether a family caregiver or friends are available to
help, or make a home care referral.

Question 6

Patient’s Current Condition

Answer 6

The ongoing physical or mental status of a patient affects whether a
medication is given and how it is administered. Assess a patient carefully
before giving any medication. For example, check a patient’s blood pressure
before giving an antihypertensive. A patient who is vomiting is unable to
take medications by mouth. Notify the patient’s health care provider when
this happens. Assessment findings serve as a baseline in evaluating the
effects of medication therapy.