How to develop better care plans byapplying nursing diagnoses to problems with

your patients' drug therapy.

BY MEREDITH ANN McCORD, RN. MS

Assistant Professor • Oregon Health Sciences University • School of Nursing • ftjrtland. Oregon

• inaccurate follow-through of in-struction• inadequate test performance• inappropriate or exaggerated behav-iors.

Your diagnosis depends upon the as-sesstnent data on and drug regimen foreach patient. The following case illus-trates how a knowledge deficit can re-sult from several causes.

Mrs. Kaminsky. age 71. entered thehospital with shortness of breath anddifficulty walking because of edemaand pain in her legs. She was diagnosedas having congestive heart failure andwas started on the following medica-tions: digoxin 0.25 mg P.O. daily, fu-rosemide (frusemide, Lasix) 40 mgP.O. daily, and potassium chloride(K-Tab) 2 tablets P.O. twice a day. Mrs.Kaminsky*s only significant medicalhistory is a 2-year history of hyper-tension, which is being monitored byher family internist. Mrs. Kaminskytakes no other drugs except for a cal-cium supplement and daily vitamins.

At this time, she can perform herroutine daily activities without short-ness of breath. Her legs remain slightly

ursing diagnoses help youidentify patient problems andestablish priorities of care.Among the most common di-agnostic labels used by nursesto develop care plans for the

management of a patient's drug regi-men are "knowledge deficit" and"noncompliancc." You may also iden-tify other nursing diagnoses, dependingupon the potential risks or adverse ef-fects occurring secondary to drug ther-apy. Consider how you might use thesediagnoses with your patients.

Knowledge deficitA knowledge deficit can occur for var-ious reasons, depending on the etiol-ogies and defining characteristics youidentify. For example, defining char-acteristics for a knowledge deficitmight include:• statement of misconception• verbalization of the problem• request for information

Adapted from the i f w pharmacutoKy textbook ClinicalPharmacology and Nursing bvCiaroUL.Saer, RN, PhD,and Bradley R. Williams, PharmD. D I9SS SpringhouseCorp.. Springhouse. Pa.

80 Nursing88, October

swollen, though greatly decreased insize from the time of admission, andher weight remains 3 pounds above herexpected dry weight. She is to be dis-charged in about 3 days if no compli-cations arise.

Mrs, Kaminsky lives alone, althoughher son and his family live nearby. Shewants to return to her home and asksquestions regarding her drugs, diet,disease, and activity levels.

In Mrs. Kaminsky's case, you maybe dealing with a "knowledge deficit,related to the new drug regimen." a"knowledge deficit, related to the pre-scribed diet." or a "knowledge deficit,related to the self-management of con-gestive heart failure" diagnosis,

NoncomplianceNoncompliance is another diagnosticlabel that can occur when you deal witha patient and a specified drug regimen.Some defining characteristics of non-compliance include:• behavior indicating failure to followa regimen, supported by direct obser-vation or statement by the patient orsignificant other

• failure on objective tests• evidence of the development of com-plications• exacerbations of the symptoms• failure to keep appointments• failure to progress• inability to set or maintain mutualgoals.

The following example illustratessome of the identifying characteristicsof noncompliance; Mr. Miller, age 65.is admitted to the hospital with an ex-acerbation of his emphysema. Withinthe past 12 months. Mr. Miller has en-tered the hospital three times with thesame medical diagnosis. Each time, hereceived intravenous antibiotics, ste-roids, and oxygen.

During Mr, Miller's present admis-sion, you note the following charac-teristics as part of the assessment, "Thepatient is alert, exhibits circumoral cy-anosis, has a respiratory rate of 32 withthe use of accessory muscles, hasbreath sounds with scattered insptra-tory and expiratory wheezes through-out and crackles in the posterior bases,has a cough productive of thick yellow-green secretions, and states his short-

ness of breath has increased over thepast 2 weeks, until he now needs as-sistance to perform his daily activities.The patient has a 50 pack-year historyof smoking; he smokes one pack perday and has refused to decrease this.He states that he quit taking his drugs2 weeks before admission because theydid not seem to make any difference inhow he felt and were expensive. Uponfurther discussion. Mr. Miller couldnot state the effects of his drugs andtreatments,"

Mr. Miller lives with his wife, whoalso has several medical problems thatrequire treatment. He is on a fixed in-come; he has insurance, the benefits ofwhich are almost exhausted; Medicare:and Social Security, During the presentadmission, the patient's respiratory sta-tus has improved. He performs his reg-ular activities with minimal shortnessof breath, although he needs oxygen atnight. Upon discharge, he is to takeprednisone 40 mg RO,. which shouldbe tapered over the next 2 weeks ac-cording to a set schedule, theophylline(Theo-Dur). metaproterenol {AlupentInhaler), beclomethasone (Vancenase

Nursing88, October 81

Inhaler), Lasix. potassium chloride(K-Lor), and cephalexin (Keflex) for10 days, and use oxygen at night.

The defining characteristics for Mr.Miller include his repeated admissionsfor the exacerbation of emphysema;discontinuance of treatment; question-able understanding of the prescribedtreatment; minimal resources to pay fortreatment; and your assessment find-ings, including shortness of breath,wheezes and crackles, the use of ac-cessory muscles for breathing, and anincreased respiratory rate. You need tocollect more information about Mr.Miller's disease knowledge and his be-liefs about the effects of the treatment.You may be dealing with "noncompli-ance, related to a misunderstanding ofthe importance of the prescribed drugregimen" or "noncompliance, relatedto a lack of financial resources."

Other diagnostic iabelsFor alteration in health maintenance,another commonly used diagnostic la-bel, the identified defining character-istics include:• a demonstrated lack of knowledgeabout basic health practices• a demonstrated lack of adaptive be-

haviors to internal or external environ-mental changes• a reported or observed inability totake responsibility for meeting basichealth practices in any or all functionalpattern areas• a history of lacking health-seekingbehavior• an expressed interest in improvinghealth behaviors• a reported or observed lack of equip-ment or financial resources or other re-sources• a reported or observed impairmentof personal support systems.

Possible nursing diagnoses related to"alteration in health maintenance" mayresemble the following: "alteration inhealth maintenance, related to the pa-tient's inability to comprehend the es-tablished drug regimen," "alteration inhealth maintenance, related to paral-ysis of the patient's right side," and"alteration in health maintenance, re-lated to a cognitive inability to managethe prescribed drug regimen."

You may formulate and use manyother nursing diagnoses, depending uponthe potential or actual adverse effects ofdrug regimens. The North AmericanNursing Diagnosis Association has ap-

proved 98 diagnostic labels, from whichthese have been developed;• potential for injury, related to anti-coagulant therapy• alteration in skin integrity, related toa reaction to the prescribed medication• alteration in oral mucous mem-branes, related to a superimposed in-fection (which could be from steroids,chemotherapy, or antibiotic use)• alteration in nutrition; less than bodyrequirements, related to nausea, an-orexia, and chemotherapy• sexual dysfunction, related to pre-scribed medications (such as propran-olol llnderall).

With such nursing diagnoses, the de-fining characteristics will depend uponthe patient's specific reaction to theparticular drug regimen. For example,with the diagnosis "potential for in-jury, related to anticoagulant therapy,"the defining characteristics may in-clude the presence of petechiae, in-creased bruising, an elevated pro-thrombin time above therapeutic lev-els, or the use of aspirin. For the di-agnosis concerning "alteration innutrition," the defining characteristicsmay include decreased weight, eatingless than 50% of meals, weakness, or

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a change in the way foods taste.Once the nursing diagnosis is for-

mulated, you can proceed to the plan-ning step of the nursing process,determining the nursing plan of carefor the patient. This consists of twomajor components: the outcome cri-teria (or patient goals) and nursing in-terventions.

Developing outcome criteriaThe outcome criteria, the first criticalcomponent of the nursing plan of care,represent patient goals and include thedesired patient behaviors or responsesthat should result from the nursing care.

Outcome criteria should exhibit cer-tain characteristics. First, each out-come criterion should be expressed asa measurable and objective statementthat can be answered with yes or no.For example. '"The patient verbalizesthe major adverse effects related to hischemotherapy drugs before discharge"or "The patient demonstrates theproper administration of her antibioticregimen before discharge."'

Next, outcome criteria should berealistic for each patient. You can'trealistically or appropriately expecta patient with a chronic respiratory dis-

order to have a PaO, in the 80s. al-though a PaO; in the 50s could be ac-ceptable.

Use only one behavior for each out-come criterion, thereby reducing thechance of ambiguity and clarifying thepatient goal for other nurses as well asfor the patient. For example, the out-come criterion "The patient lists anddemonstrates the steps necessary to usethe Alupent Inhaler" contains two be-haviors. The patient may be able to listbut not demonstrate the necessary stepsfor using the inhaler, thus producingambiguity about whether the patienthas met the goal. The statement shouldbe written as two criteria: "The patientlists the steps necessary for using theAlupent Inhaler" and "The patientdemonstrates the steps necessary forusing the Alupent Inhaler."

You can further clarify by being asconcise as possible. When developinga care plan, express the outcome cri-teria in terms of patient expectations.For example, "Cephalothin (Keflin) 2grams will be given q 6 hours" or "Thepatient will be turned q 2 hours" rep-resent nursing interventions, not pa-tient goals or outcome criteria.Remember, an outcome criterion states

lou might use all thecorrect components whenforming an outcomecriterion yet fail to write ameaningful statement.

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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 achieveafter the nursing care. In the first in-tervention about the Keflin adminis-tration, a possible outcome criterionmay be; "Patient will be free of infec-tioti in left leg ulcer" or "Patient ver-balizes the proper sequence for Keflinadministration." In the interventionabout turning the patient, a possibleoutcome criterion may be written as"patient is free of any redness overbony prominences."

Finally, each outcome criterionshould be attainable by nursing man-agement, within a designated timeframe, sueh as "by the time of dis-charge" or "after the initial teachingsession."

When writing outcome criteria, youmust consider four major components:the content area, an action verb, a timeframe, and criterion modifiers. For anexplanation of the components, alongwith examples, see Writing OutcomeCriteria.

A word of caution: You may use allof the correct components when form-ing an outcome criterion yet fail towrite a meaningful statement. For ex-ample, "The patient will develop crit-ical thinking in relation to the emer-

WRITING OUTCOMECRITERIAThe essential components of out-come criteria and examples of thosecomponents are:

CONTENT AREADescribes the subject that the pa-tient will focus on or the response tobe eiicitedt such as• action of digoxin• pulse taking

ACTION VERBDescribes how the patient willachieve the content area aim, such as• verbalize the action of digoxin• demonstrate pulse taking

TIME FRAMEGives a target date for completion ofthe outcome criteria, such as• verbalize the action of digoxin afterthe initial teaching session• demonstrate pulse taking by dis-charge

CRITERION MODIFIERSAdd specificity to the subject, ac-tion, or time, such as• verbalize correctly the major action ofdigoxin after the initial teaching session• demonstrate pulse taking before dis-charge with a degree of accuracywithin four beats of the pulse the nursetakes

gency procedures to follow when ad-verse effects of the chemotherapy oc-cur at home.'" The statement looks andsounds impressive, yet no nurse couldaccurately measure "develop criticalthinking." Remember, each outcomecriterion should represent a concisestatement that calls for one objective,measurable patient behavior or re-sponse.

Nursing interventionsAfter developing the outcome criteria,you determine the interventions neededto help the patient reach the desiredbehavior or response goals. Interven-tions are the actions that you and othernurses implement to meet the identifiedoutcome criteria. The types of inter-ventions and strategies depend upon theidentified nursing diagnosis and out-come criteria. If the nursing diagnosisstates "knowledge deficit, related tonewly prescribed Lasix."" you may fo-cus interventions on patient educationfor the actions, adverse effects, andscheduling of Lasix as well as the mon-itoring of daily weights. If the diag-nosis states "knowledge deficit, relatedto 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 takein case of an insulin reaction, dem-

onstration of self-injection techniques.and observation and guidance for the

patient when administering self-injections.

Remember, the type of strategies orinterventions depend upon the estab-

lished nursing diagnosis, outcome cri-

teria, and the individual patient. (See7110 Nursing Care Plans for examples

that illustrate the progression from di-agnosis to outcome criteria to inter-

vention.) By carefully developing anursing care plan based on these com-

ponents, you can work toward suc-cessful management of your patient'sdrug therapy and completion of the

nursing process.

TWO NURSING CARE PLANSThese two examples show how you might develop nursing care plans formanaging patient problems related to drug therapy.

NURSING DIAGNOSISKriowledge deficit, related to the new drug regimen (includes digoxin, furose-mide [frusemide, Lasix], and potassium chloride [K-Tab])

OUTCOME CRITERIABefore discharge,Mrs. Kamjnsky will:• Stale the ma|or ac-tion of each drug• Idenfify at least threeadverse reactions thatshould be brought tothe immediate atten-tion of a health carepractitioner• Describe the impor-tance of monitoringdaily weight.• Demonstrate theability to take herpulse accurately.

NURSING INTERVENTIONS• Instruct Mrs Kaminsky in the major actions ofand possible adverse reactions to each drug.• Instruct Mrs. Kaminsky about adverse reactionsthat need immediate medical attention, such as asudden change in weight, nausea, loss of appe-tite, change in affect, palpitations, or lethargy• Provide Mrs. Kaminsky with a list of adverse re-actions for home use.• Discuss the importance of monitoring dailyweight and noting more than a 2- to 3-pound in-crease.• Provide Mrs Kaminsky with written instructionsconcerning the major actions and adverse effectsof each drug as a guide for home use• Include Mrs. Kaminsky's son or significantother in the teaching if possible.• Instruct Mrs Kaminsky on methods for takingher pulse, using demonstration and practice.

NURSING DIAGNOSISNoncompliance. related to a misunderstanding of the importance of the pre-scribed drug regimen (includes theophylline [Theo-Dur], metaproterenol[Alupent Inhaler], beclomethasone [Vancenase Inhaler], furosemide ffrusemide,Lasix], potassium chloride [K-Lor], and cephalexin [Keflex])

OUTCOME CRITERIABy discharge, Mr.Miller will:• State two reasonswhy he has exacerba-tions of his emphy-sema• Identify at least threesigns that may indicateexacerbations ot hisemphysema.• Verbalize the majoractions of the pre-scribed drugs.• Describe the differ-ence between adversereactions to the drugsand the signs of exac-erbations of his em-physema.• Describe the rela-tionship between hisdrug regimen and hisemphysema.• Verbalize the impor-tance of taking hisprescribed drugs asordered

NURSING INTERVENTIONS• Discuss emphysema with Mr. Miller, noting thedisease process and why exacerbations occur—discontinuation of his drugs, progression of hisdisease or exposure to cold viruses.• Instruct Mr Miller about the signs and symp-toms that indicated a need for medical attentionbefore hospitalization and how to monitor thesigns, including increased shortness of breath,increased use of oxygen, inability to perform ac-tivities of daily living, and changes in the color ofsecretions.• Discuss and provide written information on thedrug actions.• Discuss the relationship of the prescribeddrugs to his disease• Discuss the difference between the adverse re-actions to the drugs and signs and symptomsthat indicate an exacerbation of his emphysemaor progression of the disease state. Provide Mr.Miller with a list of the information• Contact the home health agency tor follow-upcare.• Involve Mr. Miller's wife in the teaching ses-sions.• Contact social services to assess the familyfinances, and refer Mr Miller to hospital andcommunity resources.

86 Nursing88. October