Lesson 1, Topic 1
In Progress

Chapter 1: Pharmacology and the Nursing Process in LPN practice

March 28, 2021

The Lpn’s Tasks and the Nursing Process
Licensed Practical or Vocational Nurses (LPNs/LVNs) play an important role in giving nursing care, and their responsibilities are predicted to grow. There are many factors that will increase the future demand for nurses: there are now many people retiring, chronic diseases are affecting more people, older people are living longer with these chronic diseases, and the incidence of problems likely to cause increased health problems like obesity and dementia is increasing. At the same time, more registered nurses (RNs) are retiring and leaving the workforce and fewer RNs are being trained to replace them.

The LPNs/LVNs of the future will have more responsibility in this changed environment. More tasks of the RN will be delegated to the LPN/LVN. There will be a growing demand for LPN/LVN hiring in most places where health care is being offered. The patients in today’s hospitals are often very ill and require close attention. There may be many new types of technicians and technology to dispense unit-dose medications in large city hospitals, but in nursing homes or small community hospitals, there may be few nurses and little equipment. Nurses of the future may still copy medication orders from a patient’s chart and carry the medicine in paper souffle cups to the patient. To save money, many facilities may hire LPNs/LVNs in increasing numbers in these facilities. Also, the trend will continue for caregivers and patients to come from different cultural backgrounds, and there may also be co-workers from several different cultures. All these changes in the health care workplace add to stress, collision of different cultural values, difficulties in communication, and misinterpretation or confusion about why people act or make choices that they do, unless these factors are all recognized and addressed.

Although most LPNs/LVNs are familiar with the nursing process, it is likely there will be fewer RNs in the future, and LPNs/LVNs should understand clearly how to proceed in an organized way as they plan care for patients. LPNs/LVNs will find work in some of the most technically complex and challenging places offering health care, as well as working in facilities both in the United States and abroad, where they may be the health care leader and there are no fancy machines, testing equipment, or treatment plans. So the LPNs/LVNs of today must learn to use the latest equipment to provide care or to calculate drug dosages with a 2paper and pencil and do their own charting and documentation in paper charts.

Nursing actions are specific behaviors that are carefully planned. Nursing care is often complex. The well-known process that helps guide the nurse’s work in logical steps is known as the nursing process. The nursing process consists of the following five major steps:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

While LPNs/LVNs are introduced to the nursing process early in their education, all of these steps are also followed when giving medications to patients. The nursing process is shown in Figure 1-1.

 

RNs have both the knowledge and the legal authority they need to carry out all the steps of the nursing process. Their nursing actions do not require a legal order, so the RNs are acting independently. LPNs/LVNs do not have the same type of authority when they work with patients. Although LPNs/LVNs may need to rely on the RNs they work with in the planning and evaluation steps of the nursing process, they may be more independent as they collect data (assessment step) or help with the care of the patient (implementation step). For example, RNs interview the patient and do a physical examination of the patient, while LPNs/LVNs also learn information as they work with patients. It is usually the LPN/LVN who takes vital signs, checks response to medications and treatments, and monitors symptoms the patient is having. RNs and LPNs/LVNs work together to carry out medication or treatment orders written by health care providers. LPNs/LVNs may work not only with physicians, but also with nurse practitioners, physician assistants, or other types of health care providers who may legally write orders.
As you grow in the LPN/LVN role and gain experience, you will learn more complex skills that help with the nursing process. LPNs/LVNs are often given greater responsibility as they show they can do the work. In nursing homes and extended-care facilities, you may have opportunities to be a charge nurse and to manage patient care under the supervision of the RN. So it is important to master all parts of the nursing process. Experienced LPNs/LVNs will also assume more responsibility in many settings if no RN is directly available, depending upon the policies of the facility.

Assessment
An RN is legally assigned as the staff member who must perform the initial assessment for each patient. However, the LPN/LVN is often asked to assist with this task.
Assessment involves looking and listening carefully. It is a process that helps you get information about the patient, the patient’s problem, and anything 3that may influence the choice of drug to be given to the patient. This step of the nursing process is important because it gives you initial information as you begin to make a database, or record, from which all other nursing-process plans grow. Assessment means getting information by talking to the patient, watching the patient closely for signs and symptoms of problems, looking at old records, or reviewing materials that the patient may bring. When the patient is admitted to the hospital, ask carefully about any current health problems, as well as any history of illnesses, surgery, and medications taken both now and in the past. This information is important for all team members to know and helps everyone plan the patient’s care. Information in the patient’s history often directs the nurse and the physician to look for certain physical signs of illness that may be present.
Information you gather through assessment falls into two groups: subjective data and objective data. Subjective data, or information given by the patient or family, include the concerns or symptoms felt by the patient. Examples of subjective data include:
• The chief problem of the patient (in the patient’s own words)
• The detailed history of the present illness
• The medical history of the patient
• The family medical history
• Social information: the patient’s job, education level, and cultural background
• A review of problems found in different body systems
Some patient problems are more subjective than others. For example, if a patient reports pain in the abdomen, you must accept the patient’s word that the pain is present. The nurse cannot see, hear, or feel the patient’s abdominal pain—that is why it is subjective. A patient may state that he or she has trouble breathing. Although you may observe rapid breathing, the degree of difficulty cannot be measured. Information is subjective if you have to rely on the patient’s words or if the symptoms cannot be felt by anyone other than the patient. In such cases, you would report, “The patient states that….”
Objective data are “measurable” data and are obtained when the health care provider gives the patient a physical examination. It also comes from documents that patients bring with them, such as old laboratory results, electrocardiogram (ECG) printouts, or x-rays, and from information gathered during the physical examination. Patients may even bring their medicines with them to the hospital or clinic. Objective data are gathered through assessment of vital signs (respiratory rate, pulse, blood pressure, weight, height, temperature); physical findings you can see during careful inspection (close observation), palpation (feeling), percussion (feeling differences in vibrations through the skin), and auscultation (listening with the stethoscope); and the results of recent laboratory tests and diagnostic procedures.
It is especially important to get subjective and objective assessment data when the patient is first seen or on admission to the hospital. This provides initial, or baseline, information that can be used to determine how ill the patient may be. While a good deal of attention may be paid to the patient’s physical examination, over the years research has concluded that the most important information needed to make a diagnosis about what is wrong with the patient comes from the patient history. Thus, asking the patient questions and listening carefully to what he or she says or does not say is often much more helpful than the physical examination or the results of laboratory tests, which may just confirm what is learned during the history. As the LPN/LVN is often with the patient, he or she will play a very important role in continuing to listen to what the patient says and report important new information he or she learns to the other health care team members. Assessment continues throughout the period of care to see if the patient is getting better with the treatment prescribed.
The nurse may not always be the one gathering the subjective and objective data; however, the nurse and everyone else on the health care team should learn whatever information they can from the chart, the physician, the family, or other team members, and use that information to plan the patient’s care. Understanding the difference between subjective and objective information will help you in reporting, or charting, the information. For example, if the patient reports pain (subjective information), your notes should say, “The patient complains of pain” rather than “The patient has pain,” because you do not know if what the patient is feeling is actually pain or only discomfort. Much of your job in assessing will be reporting data you collect to the RN. As you learn more skills, or work in places such as nursing homes where you may have more responsibility, you will play a larger role in assessing the patient. How big a part you play in assessing the patient is defined by your state nurse practice act, which lists what LPNs/LVNs may and may not do.
Factors to Consider in Assessing the Patient
Certain information is very helpful in planning drug therapy. The nursing assessment at the time of the patient’s admission to the hospital should take special note of the drug history. You must talk to the patient, who is the first or primary source, but sometimes you also have to talk to a patient’s relatives or get old medical records, ECG results, or laboratory reports (secondary sources). Often your nursing text books or the Internet (tertiary sources) may also provide helpful information about a specific disease, medication, or procedure.
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When asking about the patient’s drug history, the nurse makes assessments in the following areas:
1. Symptoms, signs, or diseases that explain the patient’s need for medication (such as high blood glucose levels, high blood pressure, or pain)
2. Current (and sometimes past) use of all medications and drugs:
• All prescription medications (patients often forget to mention birth control pills as well as implanted birth control measures in this category)
• Over-the-counter medications such as aspirin, vitamins, laxatives, cold and sinus preparations, and antacids
• Alcohol or street drugs used for recreational purposes (such as marijuana or cocaine)
• Alternative therapies such as herbal medicines or aromatherapy
3. Any problems with drug therapy:
• Allergies: What is the patient’s response to a medicine he believes he is allergic to? Does it represent a true allergy? An adverse effect? A common side effect?
• Diseases that may prohibit or limit use of some medications (such as sickle cell anemia, glucose-6-phosphate dehydrogenase deficiency, migraine headaches, or angina)
You will also be assessing changes in patient condition or status that may influence drug therapy during the time the patient is in the hospital. This is how you will know if the medication is helping the patient or not.