PROTOTYPE DRUG: Interferon alfa 2 (Roferon-A, Intron A)
Nursing Process Focus:
Patients Receiving Hepatitis B Vaccine (Recombinant)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for related to side effects of medication |
|Assess for possible exposure to HBV. Possible signs/symptoms include: |Knowledge, Deficient related to administration of medication |
|flu-like symptoms, GI symptoms, joint or RUQ pain, jaundice, | |
|clay-colored stool, and/or dark urine. Those exposed to the virus will | |
|need a combination therapy of both the hepatitis B vaccine and the | |
|Hepatitis B Immune Globulin | |
|Obtain blood work for those with possible exposure: HBsAG viral | |
|antigen/antibodies, complete blood count, electrolytes, liver enzymes | |
|(ALT, ALP, AST, GGT, & LDH), bilirubin levels, and prothrombin time. | |
|Assess patient’s drug history/allergy to determine possible sensitivity| |
|to baker’s yeast or previous dose of hepatitis B vaccine. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Complete the series of vaccinations according to recommended immunization schedule |
|Remain free of signs and symptoms of Hepatitis B |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Identify “at risk populations” for Hepatitis. These include |Educate at “risk populations” concerning the availability of |
|People who have more than one sex |immunizations throughout the community; i.e., local health departments |
|partner in 6 months |and clinics. |
|Men who have sex with other men | |
|Sex contacts of infected persons | |
|People who inject illegal drugs | |
|Health care and public safety workers | |
|Household contacts of persons with | |
|chronic HBV | |
|Hemodialysis patients | |
|Monitor for flu-like symptoms. Those who are ill should wait until they|Instruct patient to report any flu-like symptoms, GI upset, changes in |
|recover before getting the vaccine. |urine or stool color before getting vaccine |
|Ensure infants receive the vaccine according to recommended schedule |Instruct infant caregivers of immunization schedule: |
| |within 12 hours of birth |
| |2nd dose: 1-2 months of age |
| |3rd dose: 6 months of age. |
| |The third dose should not be given before 6 months of age because this |
| |could reduce long-term protection. |
|Ensure older children, adolescents or adults receive the vaccine |Instruct patient of immunization schedule: |
|according to recommended immunization schedule. |1st dose: anytime |
| |2nd dose: 1-2 months after first dose |
| |3rd dose: 4-6 months after first dose |
| |If dose is missed, next dose should be received as soon as possible. |
|Monitor for common side effects such as soreness at injection site and |Instruct patient to notify health care provider if fever occurs or |
|fever |soreness at injection site lasts longer than a couple of days. |
|Monitor for possible allergic reactions such as difficulty breathing, |Instruct patient to notify health care provider of any signs or |
|hoarseness or wheezing, hives, paleness, weakness, tachycardia or |symptoms of an allergic reaction |
|dizziness. | |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Interferon Alfa 2A (Roferon A, Intron A)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for related to side effects of medication |
|Assess for presence/history of Cytomegalovirus and any malignancies for |Nutrition Altered, Risk for related to gastrointestinal upset secondary|
|verification of need. |to medication |
|Also check for pancreatitis, hepatic or renal disease, bone marrow |Infection, Risk related to bone marrow suppression secondary to |
|depression, and/or cardiac disease. Interferon may be contraindicated |medication |
|for patients with these disorders. |Knowledge, Deficient related to administration of medication |
|Obtain blood work: complete blood count, electrolytes, and liver enzymes| |
|Obtain weight, and vital signs especially blood pressure | |
|Assess mental alertness | |
|Assess patient’s drug history/allergy to determine possible sensitivity | |
|to interferon alpha or its components | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Remain free of fever, chills, sore throat, unusual bleeding, chest pain, palpitations, dizziness, change in mental status |
|Demonstrate the ability to self administer IM or SC injection |
|Maintain consumption of balanced diet |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor for leukopenia, neutropenia, thrombocytopenia, anemia, increased|Instruct patient to: |
|liver enzymes (due to possible bone marrow suppression and liver |Comply with all ordered laboratory tests |
|damage). |Immediately report an unusual bleeding and jaundice |
| |Avoid crowds and people with infections |
|Ensure medication is properly administered. |Instruct patient in proper technique for self administration of IM or |
| |SC injection. |
|Monitor vital signs including temperature, pulse respirations and blood |Instruct patient to: |
|pressure. (Loss of vascular tone leading to extravasation of plasma |Monitor blood pressure and pulse everyday and report to health care |
|proteins and fluids into extravasular spaces may cause hypotension and |provider any reading outside normal limits |
|arrhythmias.) |Report any palpitations to health care provider immediately |
|Monitor for common side effects such as muscle aches, fever, weight |Instruct patient to: |
|loss, loss of appetite, nausea and vomiting and arthralgia due to high |Take medication at bedtime to reduce side effects |
|doses of medications. Report to health care provider. |Use frequent mouth care and small frequent feedings to reduce |
| |gastrointestinal disturbances |
|Monitor blood glucose levels. (Blood sugar may increase in patients |Instruct patient to have blood glucose checked at regular intervals. |
|with pancreatitis.) | |
|Monitor for changes in mental status. (May cause depression, confusion,|Instruct patient to notify health care provider of any mental changes. |
|fatigue, visual disturbances, and numbness. Alpha-interferons cause or | |
|aggravate neuropsychiatric disorders. Mechanism of action | |
|undetermined.) | |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Cyclosporine (Neoral, Sandimmune)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration |Infection, Risk for related to depressed immune response secondary to |
|Assess for presence/history of organ transplant, grafting, active |medication |
|infection, and pregnancy |Injury, Risk for related to thrombocytopenia secondary to side effects |
|Assess for skin integrity, specifically look for lesions and skin color|of medication |
|Obtain blood work: complete blood count, electrolytes, and liver |Knowledge, Deficient, related to drug action and side effects |
|function | |
|Obtain vital signs especially temperature and blood pressure | |
|Assess patient’s drug history/allergy to determine possible sensitivity| |
|to polyoxyethylated castor oil | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Remain free of elevated temperature, unusual bleeding, sore throat, mouth ulcers, fatigue |
|Demonstrate complianewith all laboratory tests needed to monitor this medication |
|Demonstrate understanding of signs and symptoms of side effects related to medication |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
| Monitor renal function. (May cause nephrotoxicity. 75% of patients |Advise patient to: |
|experience decreased urine flow due to changes physicological in the |Keep good record of urine output |
|kidneys such as microcalcification and interstitial fibrosis.) |Report significant reduction in urine follow to the health care |
| |provider |
|Monitor liver function (due to an increased risk for liver toxicity). |Instruct the patient concerning the importance of regular blood work. |
|Watch for signs and symptoms of infection. (There is an increased risk |Instruct patient: |
|of infection.) |Regarding importance of good, frequent handwashing. |
| |To avoid crowds and anyone who has infection |
|Monitor vital signs especially temperature and blood pressure. (As a |Teach patients to monitor blood pressure and temperature ensuring |
|side effect of this medication especially related to those with kidney |proper use of home equipment and compliance with doctor’s appointments.|
|transplants, hypertension may occur in 10-15% of patients. Increased | |
|temperature may indicate infection.) | |
|Monitor for the following possible side effects: hirsuitism, |Advise patient to: |
|leukopenia, gingival hyperplasia, gynecomastia, sinusitis and |See a dentist on a regular basis. |
|hyperkalemia |Comply with regular laboratory assessments (complete blood count, |
| |electrolytes, and hormones levels) |
|Monitor nutritional status (due to possible weight gain). |Instruct patient in a healthy diet that avoids excessive fats and |
| |sugars. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Prednisone (Meticorten)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Nutrition: more than body requirements, Risk for Imbalanced: related to|
|Obtain complete drug history including allergies, drug history and |weight gain from medication |
|possible drug interactions |Fluid volume, Excess related to fluid retention secondary to medication|
|Assess vital signs |Body image, Disturbed related to physical changes secondary to |
|Assess for history of organ transplant, acute inflammation, diabetes |medication |
|mellitus |Injury, Risk for (infection) related to immunosuppression from |
|Obtain serum electrolytes |medication |
| |Skin Integrity, Risk for Impaired related to tissue fragility secondary|
| |to medication |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Maintain body weight within normal range |
|Remain free of edema in lower extremities |
|Demonstrate positive body image |
|Maintain intact skin integrity |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor vital signs, especially blood pressure (to determine need for |Inform patient to report to health care provider any signs and |
|possible treatment of fluid and electrolyte disorders and renal |symptoms of fluid retention; e.g. increase in weight by 2 lbs in a 1 |
|insufficiency). |week, swelling of hands and feet, difficulty breathing. |
|Use cautiously in patients with renal insufficiency (due to the drug’s | |
|ability to retain water and sodium and the main excretion of drug is by| |
|the renal system). | |
|Monitor complete blood count. (Capillaries become more permeable |Inform patient concerning the need to for periodic lab testing |
|resulting in vasoconstriction. Red blood cells increase, causing | |
|decrease in white blood cells.) | |
|Obtain medical history of myasthenia gravis (due to the possible |Instruct patient to report any difficulty in breathing to health care |
|adverse effect of exacerbation of respiratory failure). |provider immediately. |
|Monitor blood sugar. (Use cautiously in patients with diabetes mellitus|Instruct patient: |
|due to drug’s effect on blood sugar, causing hyperglycemia. Patients |May increase insulin needs while on this medication |
|may require increased doses of a glucose-lowering drug.) |To increase blood sugar monitoring and to report increased blood sugar |
| |to health care provider. |
|Monitor for signs and symptoms of infection or inflammation. |Instruct patient to: |
|(Medication may mask usual signs of infection. Use cautiously in |Avoid all contact with individuals with infections |
|patients with acute active infections. Contraindicated in patients with|Wash hands frequently and to clean all counters completely after food |
|systemic fungal infection due to the possibility of interaction with |preparation |
|the acute infection and the risk for superinfections.) | |
|Monitor compliance with medication regimen. |Instruct patient: |
| |Take medication exactly as scheduled and to never abruptly stop |
| |medication. |
| |Avoid taking any OTC drugs without checking with the health care |
| |provider. |
|Monitor intake and output (due to drug’s ability to cause water and |Instruct patient to: |
|sodium retention). |Weigh self regularly |
| |Report any sudden weight gain to the health care provider |
|Obtain history of gastrointestinal disorders. |Advise patient to take medication with food to decrease |
|(Use cautiously in patients with active peptic ulcer disease due to |gastrointestinal distress. |
|inhibiting production of cytoprotective mucous and reduction of GI | |
|mucosal blood flow that can lead to gastric ulceration.) | |
|Use extreme care during venipuncture due to capillary fragility. |Advise patient to carry some form of identification stating the |
|(Capillary fragility is due to the suppression of protein synthesis by |medication the patient is taking. |
|the glucocorticoids’ effect.) | |
|Evaluate risk for osteoporosis. (Use cautiously in patients with |Advise patient to consume nutritious low calorie foods and to increase |
|osteoporosis due to drug’s effect to cause suppression of bone |dietary calcium to combat osteoporosis. |
|formation by osteoblasts, hence to worsen symptoms of osteoporosis.) | |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Acetaminophen (Tylenol)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Pain related to ineffective response to medication |
|Obtain complete health history including allergies, drug history and |Injury, Risk for hepatic toxicity) related to adverse effects of |
|possible drug interactions. |medication |
|Obtain history of liver disease |Knowledge, Deficient related to drug action and side effects |
|Assess history of pain or fever | |
|Obtain concurrent use of anticoagulants | |
|Obtain intolerance to ASA | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Demonstrate an understanding of safe self administration of medication. |
|Demonstrate relief of pain |
|Remain free of evidence of hepatic toxicity |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor for evidence of liver dysfunction (due to acetaminophen |Advise patient to: |
|accumulation, and resulting liver damage). |Abstain from alcohol while taking this medication. |
| |Report signs of liver dysfunction including jaundice, itching, fatigue |
|Monitor renal function tests, and intake and output (due to the ability|Advise patient: |
|of acetaminophen to impair renal function as a result of toxic levels).|Lab tests to assess renal function may be necessary to prevent renal |
| |tubular necrosis. |
| |To notify health care provider if changes in urinary output occurs. |
|Monitor concurrent medication use. (Be alert to all other medications |Advise patient to: |
|that contain acetaminophen especially in combination with narcotic pain|Avoid taking any other OTC medication unless ordered by health care |
|reliever to avoid toxic levels. |provider. |
|Contraindicated for use with warfarin due to the mechanism of |Read directions carefully when using acetaminophen suspension and drops|
|inhibition of warfarin metabolism, which causes warfarin to accumulate |Not to exceed recommended daily dose of medication |
|at high levels.) | |
|Observe for intolerance to ASA for possible cross-hypersensivity to |Instruct patient to report any itching, skin rash, or difficulty |
|acetaminophen. |breathing. |
|Monitor for signs of infection, including complete blood count and |Instruct patient to report signs of infection generalized mild muscular|
|platelet count. (Acetominophen’s effects may mask infection.) |pain and headache. |
|Monitor pain level (to determine effectiveness of drug therapy). |Instruct patient to report changes in pain level to health care |
| |provider. |
|Monitor blood sugar in patients with diabetes mellitus. (Acetaminophen |Advise patient that this medication may cause hypoglycemia. |
|may decrease insulin needs.) | |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Diphendrydramine (Benadryl)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for related to drowsiness and dizziness secondary to |
|Obtain complete health history including allergies, drug history and |effects of medication |
|possible drug interactions |Gas exchange, Risk for Impaired related to respiratory secretions |
|Obtain presence/history of allergic or anaphylactic reactions |Knowledge, Deficient related to drug action and side effects. |
|Obtain vital signs | |
|Obtain history of glaucoma, diabetes mellitus, seizure disorder | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Remain free of physical injury |
|Demonstrate knowledge of drug therapy and side effects |
|Remain demonstrate relief of symptoms of allergic reaction |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor vital signs before, during, and after administration (due to |Advise patient: |
|anticholinergic effect on vital signs of decreased BP and increased |That blood pressure may decrease and heart rate increase |
|heart rate). |To report changes in vital signs to health care provider |
| |To monitor blood pressure and pulse |
|Obtain history of narrow angle glaucoma and increased intraocular |Instruct patient to report history of glaucoma to health care provider.|
|pressure. (Drug may worsen condition.) | |
|Obtain history of prostatic hypertrophy and bladder neck obstruction. |Instruct patient to report any urinary obstruction or difficulty in |
|(Both conditions are contraindicated for use with diphenhydramine due |voiding. |
|to exacerbation by anticholinergic effects and muscarinic blockade.) | |
|Monitor for respiratory conditions. (Drug may worsen conditions such as|Instruct patient to: |
|asthma.) |Report symptoms of respiratory distress to the health care provider |
| |Increase fluid intake to make expectoration easier |
|Monitor for GI conditions and distress. (Drug interferes with function |Advise patient to take medication with food to reduce gastrointestinal |
|of H1 receptors.) |distress. |
|Obtain history of diabetes mellitus. (Use cautiously in these patients |Advise patient to: |
|due to the possibility of this drug to increase hypoglycemia.) |Monitor blood sugar more frequently |
| |Inform health care provider of any abnormally low blood sugar levels. |
|Monitor neurological status especially for patients with history of |Instruct patients to: |
|seizures. (Use cautiously in these patients due to medication causing |Report aura immediately to health care provider |
|an increase in seizure activity.) |Report increase of seizure activity to health care provider |
|Use cautiously in patients with history of hyperthyroidism, |Advise patient to: |
|cardiovascular disease. (There is an increased risk of thyroid storm, |Report any unusual effects such as increased nervousness, insomnia. |
|and cardiovascular collapse.) |Report changes in vital signs |
|Monitor for side effects such as dry mouth. |Advise patient to suck on hard candy to reduce symptoms of dry mouth. |
|Closely monitor elderly patients (because of an increase incidence of |Advise patient to: |
|dizziness, sedation and hypotension). |Refrain from driving or operating heavy machinery due to sedating |
| |effects |
| |Report feeling of oversedation to the health care provider |
|Discontinue at least 4 days prior to skin tests. (Drug may increase |Inform patient to notify health care provider if they are on any H1 |
|effect to the testing and give a false positive result.) |receptor antagonists. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Fexofenadine (Allegra)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration |Injury, Risk related to drug related drowsiness |
|Obtain complete health history including allergies, drug history an |Knowledge Deficient, related to drug action and side effects |
|possible drug interactions | |
|Assess for presence/history of seasonal allergic rhinitis, allergic | |
|conjunctivitis, urticaria, angioedema | |
|Obtain vital signs | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Demonstrate understanding of drug therapy |
|Remain free of physical injury |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor neurological status of elderly patients. (The elderly are more|Advise patient to: |
|prone to syncope, sedation and dizziness due to long acting effects of |Avoid driving or operating heavy machinery until drowsiness is no |
|medication.) |longer a problem |
| |Resort symptoms of over sedation to health care provider |
|Monitor respiratory status prior to therapy (due to anticholinergic |Instruct patient to report any difficulty in breathing to health care |
|effects on respiratory system). |provider |
|Monitor for renal impairment. (Use with caution in these patients due |Advise patient to report changes in urinary pattern or output. |
|to aggravating factors related to muscarinic blockade.) | |
|Observe for allergic conditions, such as seasonal allergic rhinitis, |Instruct patient to report changes in allergic condition to health care|
|allergic conjunctivitis, and urticaria (to monitor effectiveness of |provider. |
|drug therapy). | |
|Monitor vital signs, especially heart rate and respiratory rate. |Advise patient to: |
| |Not take any OTC cold medications without first checking with the |
| |health care providerhealth care provider |
| |Abstain from the use of alcohol while taking this medication |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Fluticasone (Flonase)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration |Injury, Risk for related to adverse effects of medication |
|Obtain complete health history including allergies, drug history and |Knowledge, Deficient related to drug action and side effects |
|possible drug interactions | |
|Assess for presence or history of seasonal allergic rhinitis | |
|Obtain vital signs | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Remain free of physical injury |
|Demonstrate understanding of drug therapy |
|Demonstrate ability to adminster medication appropriately |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor respiratory function. (Drug worsens respiratory failure, asthma|Instruct patient to immediately report signs of respiratory distress to|
|attacks.) |the health care provider. |
|Monitor for concurrent use of systemic corticosteroids. (Can lead to |Instruct patient to completely disclose all other medications he/she is|
|suppression of adrenal function.) |taking. |
|Monitor for signs of infections. (Use with caution in patients with: |Instruct patient to report signs of infection to the health care |
|tuberculosis, untreated fungal, bacterial or viral infections due to |provider. |
|possible development of superinfection; ocular herpes simplex due to | |
|worsening of symptoms due to immune suppression.) | |
|Monitor for signs and symptoms of hypercorticism such as acne and |Advise patient to inform health care provider if any weight gain, |
|hyperpigmentation (due to adrenal insufficiency). |severe skin conditions occur, hyperactivity. |
|Provide humidification (to decrease crusting and drying of nasal |Instruct patient: |
|passages). |To report irritation of nasal passages to health care provider |
| |To wash cap and nosepiece with warm water after each use |
| |That transient burning of the nasal passages as well as sneezing are |
| |common side effects |
|Observe for proper use of medication. |Instruct patient: |
| |In proper technique for use of nasal inhaler |
| |To shake inhaler prior to use |
| |That medication will be most effective if nasal passages are clear |
| |before use |
| |To use only prescribed amount to avoid systemic side effects |
| |That this medication does not provide immediate symptom relief |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming the patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus
Patients Receiving Oxymetazoline (Afrin)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for (nosebleed) related to adverse effects of medication|
|Obtain complete health history including allergies, drug history and |Tissue Perfusion, Risk for Ineffective related to adverse effects of |
|possible drug interactions |medication |
|Assess for presence or history of nasal congestion due to allergic |Knowledge, Deficient related to drug action, side effects, and |
|conditions, nasal surgery, middle ear infections (treatment and |administration |
|prevention) | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Demonstrate an ability to use a nasal inhaler. |
|Remain free of physical injury |
|Maintain effective tissue perfusion |
|Demonstrate knowledge of drug therapy |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Evaluate pupil size and respiratory status before administration. |Inform patient: |
|(Drug stimulates alpha1-adrenergic receptors that may cause |That pupil constriction and respiratory depression may occur |
|constricted pupils and respiratory depression.) |To immediately report respiratory distress to the health care |
| |provider |
|Obtain history of diabetes mellitus (Use cautiously in these patients|Instruct patient: |
|due to possible interaction of drug with glucose-lower agents.) |To monitor their glucose levels frequently when on this medication |
| |To notify their health care provider for any abnormalities in their |
| |results. |
| |May need increased doses of glucose-lowering agents |
|Monitor compliance with medication regimen. (Rebound congestion will |Instruct patient: |
|occur if medication is used for longer than 5 days due to prolonged |Not to use medication longer than 5 days. |
|use, patient must use more and larger doses of drug.) |To notify health care provider if rebound congestion occurs |
| |In proper technique for administering nose drops |
| |To wash hands before and after using nose drops |
| |To rinse dropper in hot water after each use |
|Obtain history hyperthyroidism (Use cautiously in patients with |Instruct patient to report nervousness, shaking, tremors, fever, |
|hyperthyroidism due to central nervous system stimulation by drug’s |rapid heart beat and breathing to the health care provider. |
|effect that possibility would cause an exacerbation of the disease | |
|process.) | |
|Monitor vital signs, especially pulse and respiration. (Drug has |Advise patient to: |
|cardiovascular effects by stimulation of alpha1-adrenergic |Use only the prescribed amount |
|receptors.) |Monitor blood pressure at same time daily and record. |
| |Report any abnormal results to health care provider. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Epinephrine (Adrenalin)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Tissue perfusion, Risk for Ineffective related to cardiovascular |
|Obtain complete health history including allergies, drug history and |effects of medication |
|possible drug interactions |Sleep pattern, Disturbed, related to CNS effects of medication |
|Assess for presence/history of Anaphylactic shock, asthma, |Nutrition Impaired: less than body requirements related to anorexia |
|cardiopulmonary resuscitation |secondary to medication |
|simple glaucoma, ventricular |Knowledge Deficient, related to drug action and side effects |
|fibrillation, croup, septic shock, | |
|wheezing | |
|Obtain vital signs | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Demonstrate understanding of the risks and benefits of drug therapy. |
|Maintain adequate tissue perfusion |
|Maintain adequate sleep |
|Demonstrate maintenance of weight within normal range |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor vital signs and lung sounds, including croup and wheezing (to |Instruct patient to report changes in respiratory status to the |
|determine effectiveness of drug therapy). |health care provider. |
|Monitor blood glucose. (Use with caution in patients with diabetes |Advise patient to monitor blood glucose frequently during treatment. |
|mellitus due to epinephrine’s effect of increasing hyperglycemia.) | |
|Obtain history of closed angle glaucoma. (Drug dilates the pupil, which|Instruct patient to immediately report vision changes to the health |
|may lead to worsening of condition.) |care provider. |
|Use with caution in patients with hyperthyroidism (due to exacerbation |Instruct the patient to notify the health care provider if they |
|of thyroid crisis). |experience; increased heart rate, fever, nervousness, tremors. |
|Monitoring cardiovascular status (Cardiac arrhythmias may occur and may|Advise patient that cardiac monitoring will occur while receiving |
|lead to ventricular fibrillation. Hypertensive crisis may occur.) |this medication. |
| | |
|Monitor neurological status. (Drug may cause cerebral hemorrhage.) |Instruct patient to immediately report the first signs of severe |
| |headache. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving Celecoxib
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for (Gastrointestinal bleeding) related to adverse effects|
|Obtain complete health history including allergies, drug history and |of the medication |
|possible drug interactions. |Mobility, Impaired physical related to joint disease |
|Assess for presence/history |Knowledge Deficient, related to drug action and side effects |
|Rheumatoid arthritis | |
|Osteoarthritis | |
|Congestive heart failure | |
|Hypertension | |
|Renal disease | |
|Pregnancy | |
|assess renal function tests, e.g. BUN, creatinine levels | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Avoid evidence of gastrointestinal bleeding |
|Demonstrate compliance with lifestyle modifications necessary for successful medication therapy. |
|Demonstrate knowledge of drug action and side effects of drug |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor for congestive heart failure, fluid retention, hypertension, |Advise patient to: |
|and renal disease. (Use cautiously in these patients, as drug may cause|Report any difficulty breathing to the health care provider immediately|
|increased edema and fluid retention.) |Report to the health care provider immediately, any blood in the stool,|
|Monitor vital signs (especially pulse and blood pressure) for baseline |any swelling or skin rash or any yellow coloration to the eyes or skin |
|information and to monitor the drug’s possible effect of COX 1 | |
|inhibition on renal vasodilation. | |
|Monitor intake and output (due to possible drug interactions that may |Instruct patient to report changes in urinary output to the health care|
|decrease function of reabsorption of water at the loop of Henle). |provider. |
|Monitor for gastrointestinal distress such as nausea, diarrhea, |Advise patient to take medication with food if gastrointestinal |
|abdominal pain, or flatulence. |distress is a problem. |
|Monitor liver function, complete blood count, BUN, serum creatinine, |Instruct patient to keep all appointments for laboratory tests. |
|and serum electrolytes. | |
|Monitor lithium levels in patients who are taking lithium. (Celecoxib |Encourage patients to comply with lithium serum levels lab tests as |
|may alter established lithium levels.) |ordered by health care provider. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
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