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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 • inaccurate follow-through of in-


identify patient problems and struction
establish priorities of care. • inadequate test performance
Among the most common di- • inappropriate or exaggerated behav-
agnostic labels used by nurses iors.
to develop care plans for the Your diagnosis depends upon the as-
management of a patient's drug regi- sesstnent data on and drug regimen for
men are "knowledge deficit" and each patient. The following case illus-
"noncompliancc." You may also iden- trates how a knowledge deficit can re-
tify other nursing diagnoses, depending sult from several causes.
upon the potential risks or adverse ef- Mrs. Kaminsky. age 71. entered the
fects occurring secondary to drug ther- hospital with shortness of breath and
apy. Consider how you might use these difficulty walking because of edema
diagnoses with your patients. and pain in her legs. She was diagnosed
as having congestive heart failure and
Knowledge deficit was started on the following medica-
A knowledge deficit can occur for var- tions: digoxin 0.25 mg P.O. daily, fu-
ious reasons, depending on the etiol- rosemide (frusemide, Lasix) 40 mg
ogies and defining characteristics you P.O. daily, and potassium chloride
identify. For example, defining char- (K-Tab) 2 tablets P.O. twice a day. Mrs.
acteristics for a knowledge deficit Kaminsky*s only significant medical
might include: history is a 2-year history of hyper-
• statement of misconception tension, which is being monitored by
• verbalization of the problem her family internist. Mrs. Kaminsky
• request for information takes no other drugs except for a cal-
cium supplement and daily vitamins.
Adapted from the if w pharmacutoKy textbook Clinical At this time, she can perform her
Pharmacology and Nursing bvCiaroUL.Saer, RN, PhD, routine daily activities without short-
and Bradley R. Williams, PharmD. D I9SS Springhouse
Corp.. Springhouse. Pa. ness of breath. Her legs remain slightly

80 Nursing88, October
swollen, though greatly decreased in • failure on objective tests ness of breath has increased over the
size from the time of admission, and • evidence of the development of com- past 2 weeks, until he now needs as-
her weight remains 3 pounds above her plications sistance to perform his daily activities.
expected dry weight. She is to be dis- • exacerbations of the symptoms The patient has a 50 pack-year history
charged in about 3 days if no compli- • failure to keep appointments of smoking; he smokes one pack per
cations arise. • failure to progress day and has refused to decrease this.
Mrs, Kaminsky lives alone, although • inability to set or maintain mutual He states that he quit taking his drugs
her son and his family live nearby. She goals. 2 weeks before admission because they
wants to return to her home and asks The following example illustrates did not seem to make any difference in
questions regarding her drugs, diet, some of the identifying characteristics how he felt and were expensive. Upon
disease, and activity levels. of noncompliance; Mr. Miller, age 65. further discussion. Mr. Miller could
In Mrs. Kaminsky's case, you may is admitted to the hospital with an ex- not state the effects of his drugs and
be dealing with a "knowledge deficit, acerbation of his emphysema. Within treatments,"
related to the new drug regimen." a the past 12 months. Mr. Miller has en- Mr. Miller lives with his wife, who
"knowledge deficit, related to the pre- tered the hospital three times with the also has several medical problems that
scribed diet." or a "knowledge deficit, same medical diagnosis. Each time, he require treatment. He is on a fixed in-
related to the self-management of con- received intravenous antibiotics, ste- come; he has insurance, the benefits of
gestive heart failure" diagnosis, roids, and oxygen. which are almost exhausted; Medicare:
During Mr, Miller's present admis- and Social Security, During the present
Noncompliance sion, you note the following charac- admission, the patient's respiratory sta-
Noncompliance is another diagnostic teristics as part of the assessment, "The tus has improved. He performs his reg-
label that can occur when you deal with patient is alert, exhibits circumoral cy- ular activities with minimal shortness
a patient and a specified drug regimen. anosis, has a respiratory rate of 32 with of breath, although he needs oxygen at
Some defining characteristics of non- the use of accessory muscles, has night. Upon discharge, he is to take
compliance include: breath sounds with scattered insptra- prednisone 40 mg RO,. which should
• behavior indicating failure to follow tory and expiratory wheezes through- be tapered over the next 2 weeks ac-
a regimen, supported by direct obser- out and crackles in the posterior bases, cording to a set schedule, theophylline
vation or statement by the patient or has a cough productive of thick yellow- (Theo-Dur). metaproterenol {Alupent
significant other green secretions, and states his short- Inhaler), beclomethasone (Vancenase

Nursing88, October 81
Inhaler), Lasix. potassium chloride haviors to internal or external environ- proved 98 diagnostic labels, from which
(K-Lor), and cephalexin (Keflex) for mental changes these have been developed;
10 days, and use oxygen at night. • a reported or observed inability to • potential for injury, related to anti-
The defining characteristics for Mr. take responsibility for meeting basic coagulant therapy
Miller include his repeated admissions health practices in any or all functional • alteration in skin integrity, related to
for the exacerbation of emphysema; pattern areas a reaction to the prescribed medication
discontinuance of treatment; question- • a history of lacking health-seeking • alteration in oral mucous mem-
able understanding of the prescribed behavior branes, related to a superimposed in-
treatment; minimal resources to pay for • an expressed interest in improving fection (which could be from steroids,
treatment; and your assessment find- health behaviors chemotherapy, or antibiotic use)
ings, including shortness of breath, • a reported or observed lack of equip- • alteration in nutrition; less than body
wheezes and crackles, the use of ac- ment or financial resources or other re- requirements, related to nausea, an-
cessory muscles for breathing, and an sources orexia, and chemotherapy
increased respiratory rate. You need to • a reported or observed impairment • sexual dysfunction, related to pre-
collect more information about Mr. of personal support systems. scribed medications (such as propran-
Miller's disease knowledge and his be- Possible nursing diagnoses related to olol llnderall).
liefs about the effects of the treatment. "alteration in health maintenance" may With such nursing diagnoses, the de-
You may be dealing with "noncompli- resemble the following: "alteration in fining characteristics will depend upon
ance, related to a misunderstanding of health maintenance, related to the pa-^ the patient's specific reaction to the
the importance of the prescribed drug tient's inability to comprehend the es- particular drug regimen. For example,
regimen" or "noncompliance, related tablished drug regimen," "alteration in with the diagnosis "potential for in-
to a lack of financial resources." health maintenance, related to paral- jury, related to anticoagulant therapy,"
ysis of the patient's right side," and the defining characteristics may in-
Other diagnostic iabels "alteration in health maintenance, re- clude the presence of petechiae, in-
For alteration in health maintenance, lated to a cognitive inability to manage creased bruising, an elevated pro-
another commonly used diagnostic la- the prescribed drug regimen." thrombin time above therapeutic lev-
bel, the identified defining character- You may formulate and use many els, or the use of aspirin. For the di-
istics include: other nursing diagnoses, depending upon agnosis concerning "alteration in
• a demonstrated lack of knowledge the potential or actual adverse effects of nutrition," the defining characteristics
about basic health practices drug regimens. The North American may include decreased weight, eating
• a demonstrated lack of adaptive be- Nursing Diagnosis Association has ap- less than 50% of meals, weakness, or

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82 Nursing88, October circis RSVP # ig, of can toll-frM. SM page 1S2. CIrcIa RSVP #187. S M (wgt 152.
a change in the way foods taste. order to have a PaO, in the 80s. al-
Once the nursing diagnosis is for- though a PaO; in the 50s could be ac-
mulated, you can proceed to the plan- ceptable.
ning step of the nursing process, Use only one behavior for each out-
determining the nursing plan of care come criterion, thereby reducing the
for the patient. This consists of two chance of ambiguity and clarifying the
major components: the outcome cri- patient goal for other nurses as well as
teria (or patient goals) and nursing in- for the patient. For example, the out-
terventions. come criterion "The patient lists and lou might use all the
demonstrates the steps necessary to use correct components when
Developing outcome criteria the Alupent Inhaler" contains two be-
The outcome criteria, the first critical haviors. The patient may be able to list forming an outcome
component of the nursing plan of care, but not demonstrate the necessary steps criterion yet fail to write a
represent patient goals and include the for using the inhaler, thus producing meaningful statement.
desired patient behaviors or responses ambiguity about whether the patient
that should result from the nursing care. has met the goal. The statement should
Outcome criteria should exhibit cer- be written as two criteria: "The patient
tain characteristics. First, each out- lists the steps necessary for using the
come criterion should be expressed as Alupent Inhaler" and "The patient
a measurable and objective statement demonstrates the steps necessary for
that can be answered with yes or no. using the Alupent Inhaler."
For example. '"The patient verbalizes You can further clarify by being as
the major adverse effects related to his concise as possible. When developing
chemotherapy drugs before discharge" a care plan, express the outcome cri-
or "The patient demonstrates the teria in terms of patient expectations.
proper administration of her antibiotic For example, "Cephalothin (Keflin) 2
regimen before discharge."' grams will be given q 6 hours" or "The
Next, outcome criteria should be patient will be turned q 2 hours" rep-
realistic for each patient. You can't resent nursing interventions, not pa-
realistically or appropriately expect tient goals or outcome criteria.
a patient with a chronic respiratory dis- Remember, an outcome criterion states

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CIrcl* RSVP #184. S M pag* 152. CIrcF* RSVP #19, or call toll-(rM. S M page 152. Nursing88, October 83
what you want the patient to achieve gency procedures to follow when ad-
after the nursing care. In the first in- WRITING OUTCOME verse effects of the chemotherapy oc-
tervention about the Keflin adminis- CRITERIA cur at home.'" The statement looks and
tration, a possible outcome criterion The essential components of out- sounds impressive, yet no nurse could
may be; "Patient will be free of infec- come criteria and examples of those accurately measure "develop critical
tioti in left leg ulcer" or "Patient ver- components are: thinking." Remember, each outcome
balizes the proper sequence for Keflin CONTENT AREA criterion should represent a concise
administration." In the intervention Describes the subject that the pa- statement that calls for one objective,
about turning the patient, a possible tient will focus on or the response to
measurable patient behavior or re-
outcome criterion may be written as be eiicitedt such as
• action of digoxin sponse.
"patient is free of any redness over • pulse taking
bony prominences." Nursing interventions
ACTION VERB After developing the outcome criteria,
Finally, each outcome criterion
Describes how the patient will
should be attainable by nursing man- achieve the content area aim, such as you determine the interventions needed
agement, within a designated time • verbalize the action of digoxin to help the patient reach the desired
frame, sueh as "by the time of dis- • demonstrate pulse taking behavior or response goals. Interven-
charge" or "after the initial teaching tions are the actions that you and other
session." TIME FRAME nurses implement to meet the identified
Gives a target date for completion of
When writing outcome criteria, you outcome criteria. The types of inter-
the outcome criteria, such as
must consider four major components: • verbalize the action of digoxin after ventions and strategies depend upon the
the content area, an action verb, a time the initial teaching session identified nursing diagnosis and out-
frame, and criterion modifiers. For an • demonstrate pulse taking by dis- come criteria. If the nursing diagnosis
explanation of the components, along charge states "knowledge deficit, related to
with examples, see Writing Outcome newly prescribed Lasix."" you may fo-
CRITERION MODIFIERS
Criteria. Add specificity to the subject, ac-
cus interventions on patient education
tion, or time, such as for the actions, adverse effects, and
A word of caution: You may use all
• verbalize correctly the major action of scheduling of Lasix as well as the mon-
of the correct components when form- digoxin after the initial teaching session itoring of daily weights. If the diag-
ing an outcome criterion yet fail to • demonstrate pulse taking before dis- nosis states "knowledge deficit, related
write a meaningful statement. For ex- charge with a degree of accuracy
within four beats of the pulse the nurse
to the administration of daily insulin.""
ample, "The patient will develop crit-
takes you might develop interventions that
ical thinking in relation to the emer-

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Circia HSVP #30, or call toll-fra«. See psga 152.


84 Nursing88, October Circle RSVP #19, or call lolMrM. S M paga 152.
focus on education for ihe action and teria, and the individual patient. (See
adverse effects of insuiin. steps to take 7110 Nursing Care Plans for examples
in case of an insulin reaction, dem- that illustrate the progression from di-
onstration of self-injection techniques. agnosis to outcome criteria to inter-
' America's first name and observation and guidance for the vention.) By carefully developing a
in namepms and nurse accessories. patient when administering self- nursing care plan based on these com-
injections. ponents, you can work toward suc-
Reeves Namepins. The choice of professionals! Remember, the type of strategies or cessful management of your patient's
interventions depend upon the estab- drug therapy and completion of the
lished nursing diagnosis, outcome cri- nursing process.

WENDY
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, furose-
mide [frusemide, Lasix], and potassium chloride [K-Tab])

OUTCOME CRITERIA NURSING INTERVENTIONS


Before discharge, • Instruct Mrs Kaminsky in the major actions of
Mrs. Kamjnsky will: and possible adverse reactions to each drug.
• Stale the ma|or ac- • Instruct Mrs. Kaminsky about adverse reactions
tion of each drug that need immediate medical attention, such as a
MRS.S sudden change in weight, nausea, loss of appe-
559 • Idenfify at least three
w t t m P H L B ' V L E " gola Of siluei Duototte (polistied edges, adverse reactions that tite, change in affect, palpitations, or lethargy
salin center). Florentine (textured]. Satin (bfushed). PallsABd (shiny) should be brought to • Provide Mrs. Kaminsky with a list of adverse re-
or Feattiercut Edge, (ettrs}. the immediate atten- actions for home use.
METAL FRflMED STYLE satin plastic nameplate set in our hand-
some regiilai gold or siluer glossed naraepin frame, or choose tion of a health care • Discuss the importance of monitoring daily
teathercut trartie at slight extra cost. practitioner weight and noting more than a 2- to 3-pound in-
PLASTIC LAMINATE Jewelers pinDack, edges match letterfng
color Finest Reeves ctattstiianship ttiroughout • Describe the impor- crease.
tance of monitoring • Provide Mrs Kaminsky with written instructions
Spragtie-Rappaport TYPE daily weight. concerning the major actions and adverse effects
• Demonstrate the of each drug as a guide for home use
STETHOSCOPE Vou cannot own a finer quality
Spragje-Rappaporl stetho- ability to take her • Include Mrs. Kaminsky's son or significant
scope' Reeves owr brand is the pulse accurately. other in the teaching if possible.
ultimate design for accuracy, • Instruct Mrs Kaminsky on methods for taking
precision-constructed for a life-
time of dependability Incfudes her pulse, using demonstration and practice.
compiefe head, diaphragm, bell,
and eartip selections Guaran- NURSING DIAGNOSIS
teed 10 years Order today Noncompliance. related to a misunderstanding of the importance of the pre-
\ FHEE ENGRAVING scribed drug regimen (includes theophylline [Theo-Dur], metaproterenol
ot name or Initials. [Alupent Inhaler], beclomethasone [Vancenase Inhaler], furosemide ffrusemide,
Lasix], potassium chloride [K-Lor], and cephalexin [Keflex])
Each 3 5 .6;1_1 12+.
MXSA311 20,95 18 86 16.75 15.71
OUTCOME CRITERIA NURSING INTERVENTIONS
TO: REEVES CO.. Boi T I S - N . Atlleboro. Mass. 0 2 7 0 3
By discharge, Mr. • Discuss emphysema with Mr. Miller, noting the
Miller will: disease process and why exacerbations occur—
• State two reasons discontinuation of his drugs, progression of his
why he has exacerba- disease or exposure to cold viruses.
Use e«trs sheet tor additional itetni or orders. tions of his emphy- • Instruct Mr Miller about the signs and symp-
FREE
ENGRAVING Desired sema toms that indicated a need for medical attention
TOORDERNAMEPINS, chf ch off your choicesmcharlBela* Print • Identify at least three before hospitalization and how to monitor the
engrflvingrtflsifeclin piflcp prcfujdefj Please submil group ordpr^ on
plain paper EncloiP yaw mailing address. Prinl clearly signs that may indicate signs, including increased shortness of breath,
exacerbations ot his increased use of oxygen, inability to perform ac-
Namepin Discounts 5-9:10% 10-14:15% 1S+: 20%
emphysema. tivities of daily living, and changes in the color of
• Verbalize the major secretions.
actions of the pre- • Discuss and provide written information on the
scribed drugs. drug actions.
• Describe the differ- • Discuss the relationship of the prescribed
ence between adverse drugs to his disease
reactions to the drugs • Discuss the difference between the adverse re-
and the signs of exac- actions to the drugs and signs and symptoms
erbations of his em- that indicate an exacerbation of his emphysema
physema. or progression of the disease state. Provide Mr.
I ENGRAVE NAMEPIN AS FOLLCWS: • Describe the rela- Miller with a list of the information
tionship between his • Contact the home health agency tor follow-up
drug regimen and his care.
emphysema. • Involve Mr. Miller's wife in the teaching ses-
• Verbalize the impor- sions.
I enclose $„ .plusS1.65han(l.;posl.T0TftLJ
Mass, residents add S% Sales Tai tance of taking his • Contact social services to assess the family
VISA. MASTEHCARD wei':oniGtt Please 5Ut>mn Card No.. ExpiiB- prescribed drugs as finances, and refer Mr Miller to hospital and
tion Date anrJ Si^nalure with oroei or Dhore 5a5-Z22-je77 ordered community resources.
Please enclose your nsme.'address with this order.

86 Nursing88. October