3.4 Applying the Nursing Process to Administering Antimicrobials

Now that we have reviewed basic concepts of antimicrobials and administration considerations, let’s apply the nursing process. The nursing process consists of the steps of assessment, diagnosis, outcome identification, planning, implementation of interventions, and evaluation. For more information about the nursing process, refer to the “Ethical and Professional Foundations of Safe Medication Administration by Nurses” section in Chapter 1. This book will broadly discuss considerations related to the nursing process steps of assessment, implementation, and evaluation because the steps of diagnosis, outcome identification, and planning steps are specifically tailored to each individual client.

Assessment

Although there are numerous details to consider when administering medications, it is important to first think  about what you are administering and why.

First Think WHY?

Antimicrobials are prescribed to prevent or treat infection. If a client is prescribed an antimicrobial, the nursing assessment should include looking for signs and symptoms of infection. The nurse should always know WHY the client is receiving an antimicrobial in order to evaluate if the treatment is resulting in the client improving or deteriorating.

The nurse collects pre-administration information as part of the assessment process. Typical data collected at the start of a shift for a client receiving an antimicrobial for an infection include a baseline temperature, heart rate, blood pressure, and respiratory rate. The nurse also reviews the most recent white blood cell count. Focused assessments are then made based on the type of infection. For example, if a client has a wound infection, the wound should be assessed. If a client has a respiratory infection, the nurse should assess the client’s lung sounds. If a client has a urinary tract infection (UTI), symptoms related to a UTI should be assessed.

Additionally, whenever a client has an infection, it is important to continually monitor for the potential development of sepsis, a life-threatening condition caused by severe infection. Early signs of sepsis include new onset confusion, elevated heart rate, decreased blood pressure, increased respiratory rate, and fever.

Additional baseline information to collect prior to the administration of any new medication order includes a patient history, current medication use including herbals or other supplements, and history of allergy or previous adverse response. Many clients with an allergy to one type of antimicrobial agent may experience cross-reactivity to other classes. This information should be appropriately communicated to the prescribing provider prior to the administration of any antimicrobial medication.

Implementation of Interventions

With administering antimicrobial medication, the nurse anticipates additional interventions associated with the effects of the medications. For example, antimicrobials often cause gastrointestinal (GI) upset such as nausea and diarrhea. The client should be educated about these potential side effects and interventions should be implemented to minimize these occurrences. For example, the nurse may instruct the client to take specific antimicrobials with food to diminish the chance of GI upset, whereas other medications should be taken on an empty stomach for optimal absorption.

Hypersensitivity/allergic reactions are always a potential adverse reaction to antibiotics, especially when administering the first dose. Hypersensitivity reactions are immune responses that are exaggerated or inappropriate to an antigen and can range from itching to anaphylaxis. Anaphylaxis is a medical emergency that can cause life-threatening respiratory failure and circulatory collapse. Early signs of anaphylaxis include, but are not limited to, hives and itching, the feeling of a swollen tongue or throat, shortness of breath, dizziness, and low blood pressure. The nurse should monitor for these reactions and respond appropriately by immediately notifying the provider.

Evaluation

Nurses evaluate the effectiveness of a client’s response to medication. With antimicrobial medications, the nurse assesses for decreasing signs of infection, such as fever or white blood cell count, indicating the client is improving. These findings should be documented to reflect the client’s response to treatment.

The nurse also monitors for signs of worsening infection and communicate them to the provider. For example, increasing white blood cell count, temperature, heart rate, and respiratory rate may indicate that the client is developing sepsis. These signs of worsening clinical status require prompt notification of the health care provider and intervention to prevent further clinical deterioration.

Additionally, clients receiving antibiotics should be closely monitored for developing superinfections such as C-difficile (C-diff) that causes frequent, foul-smelling stools. The provider must be promptly notified of suspected C-diff for additional treatment, as well as the implementation of contact isolation precautions to prevent the spread of infection. Furthermore, C-diff requires the use of soap and water for hand hygiene, not hand sanitizer, because hand sanitizer will not kill the C-diff spores.^[1]