PROTOTYPE DRUG: Chlorothiazide (Diuril)



Nursing Process Focus:

Patients Receiving Chlorothiazide (Diuril)

|Assessment |Potential Nursing Diagnoses |

|Prior to administration: |Comfort, impaired, nausea/vomiting, related to effects of |

|Obtain complete health history including allergies, drug history |chlorothiazide |

|and possible drug interactions |Falls, risk for, related to orthostatic hypotension secondary to |

|Assess for presence/history of serious kidney dysfunction, |medication |

|hypokalemia, decreased liver function, diabetges mellitus, |Knowledge, deficient, related to effects of thiazide diuretics |

|decreased liver function |Fluid volume, deficient, related to excessive dose of |

|Lab values for CBC, BUN, creatinine, electrolytes, uric acid, |chlorothiazide |

|blood glucose |Noncompliance, recommended medication regime, related to |

|Obtain vital signs |unpleasant side effects, misunderstanding of need to take |

|Assess for peripheral edema |medication exactly as ordered |

|Obtain body weight | |

|Planning: Patient Goals and Expected Outcomes |

|Patient will |

|Take medication as ordered, without increasing or decreasing unless recommended by health care provider |

|Experience no side effects or adverse reactions |

|Experience increased urinary output, decreased blood pressure |

|Demonstrate knowledge of mechanisms of action of chlorothiazide |

|Demonstrate knowledge of eating potassium-rich diet or of taking potassium supplement, but not both unless specifically recommended |

|by health care provider |

|Implementation |

| Interventions and (Rationales) | Patient Education/Discharge Planning |

|Obtain history of drug allergies. (Chlorothiazide is a |Instruct patient to report all allergies to the health care |

|sulfonamide, so it patient is sensitive to one sulfa drug, he/she|provider. |

|will not be able to take it.) | |

|Monitor renal function. (Chlorothiazide cannot be given to |Instruct patient to monitor intake and output and report changes |

|patient with severe renal dysfunction or anuria.) |in urine amount to health care provider. |

|Monitor potassium levels. (Chlorothiazide decreases potassium |Instruct patient to: |

|levels, patient must be monitored closely for normal levels |Recognize signs and symptoms of hypokalemia, including leg |

|throughout therapy.) |cramps, nausea, vomiting, cardiac dysrhytmias. |

| |Report symptoms to health care provider |

| |Add potassium rich foods to diet such as citrus fruit and melons |

|Monitor blood sugar levels if patient is diabetic or |Instruct patient to: |

|pre-diabetic. (Chlorothiazide may cause hyperglycemia and |Monitor blood glucose closely. |

|glycosuria. Patient may need dosage adjustments of hypoglycemic |Report consistent hyperglycemia to the health care provider |

|drugs.) | |

|Monitor for gout. (Patient with gout may experience hyperuricemia|Instruct patient to report worsening of symptoms of gout to the |

|without symptoms, secondary to chlorothiazide’s interference with|health care provider. |

|uric acid excretion.) | |

|Monitor intake and output for equality between intake and output |Instruct patient to report either oliguria or extreme diuresis |

|in a 24-hour period. (Excessive diuresis, or oliguria, can lead |immediately. |

|to electrolyte imbalances.) | |

|Provide safe environment. (Chlorothiazide may cause Orthostatic |Teach patient/caregivers: |

|hypotension placing patient at risk for falls.) |Measures to decrease falls if orthostatic hypotension occurs |

| |To change position slowly, rise slowly |

|Evaluation of Outcome Criteria |

|Evaluatge the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |

Nursing Process Focus:

Patients Receiving SPIRONOLACTONE (Aldactone)

|Assessment |Potential Nursing Diagnoses |

|Prior to administration: |Body image, disturbed (gynecomastia in males, hirsutism in |

|Obtain complete health history including allergies, drug history |females) related to anti-estrogen effects of spironolactone |

|and possible drug interactions. |Diarrhea, related to side effects of medication |

|Vital signs |Fluid volume, deficient, risk for, related to excessive doses of |

|Serum, electrolytes, creatinine, CBC, ABGs, BUN) |spironolactone |

|Obtain body weight |Knowledge, deficient, related to no effects of medication |

|Assess for presence/history of decreased liver or kidney function| |

|Planning: Patient Goals and Expected Outcomes |

|The patient will: |

|Experience increased diuresis. |

|Exhibit decreased or absent edema or crackles. |

|Demonstrate blood pressure and potassium values within normal limits |

|Demonstrate knowledge of mechanisms of action of spironolactone, side effects and adverse reactions |

|Mainatain absence of diarrhea |

|Implementation |

| Interventions and (Rationales) | Patient Education/Discharge Planning |

|Monitor renal function. (Spironolactone cannot be used if anuria,|Instruct patient to report changes in urinary output to the health|

|worsening decreased kidney function, or acute renal insufficiency|care provider. |

|is present. Use cautiously if BUN is 40 or above.) | |

|Monitor serum potassium levels results for impending hypokalemia |Advise patient regarding signs and symptoms of hypokalemia or |

|or hyperkalemia. (The patient is at risk for cardiac |hyperkalemia including leg cramps, nausea, vomiting, irregular |

|dysrhytmias.) |heart rhythm. |

|Monitor daily weight and intake and output (to determine fluid |Instruct patient/caregivers to: |

|loss). |Weigh daily or on schedule recommended by health care provider, |

| |and record, and report changes of >3 pounds if doing daily |

| |weights, or >5 pounds if once weekly weights |

| |Weigh at same time every day, same scale, and in same amount of |

| |clothing, in order to get most accurate weight possible |

|Monitor for symptoms of metabolic acidosis. |Instruct patient caregivers to monitor for drowsiness, |

| |restlessness. |

|Monitor diet for food high in potassium (may lead to |Instruct patient to: |

|hyperkalemia). |Avoid foods with high potassium content (bananas, oranges, orange |

| |juice, dried apricots, Sanka, etc.) |

| |Avoid use of potassium-based salt substitutes, and to get |

| |permission of health care provider before using any salt |

| |substitute |

|Monitor for side effects/adverse reactions. |Advise patient/caregiver to be aware of and report: |

| |nausea/vomiting, diarrhea, burning of tongue, lethargy, confusion,|

| |headache, dizziness, drowsiness, gout, rash, or urticaria |

|Monitor for sexual changes. (Patient may experience decreased |Instruct patient/caregiver to report changes to health care |

|libido, hirsutism in females, gynecomastia and/or impotence in |provider immediately, but not to abruptly discontinue taking |

|males, irregular menses or possibly amenorrhea, post-menopausal |spironolactone unless recommended by health care provider. |

|bleeding, or deepening of the voice in females.) | |

|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 SODIUM BICARBONATE

|Assessment |Potential Nursing Diagnoses |

|Prior to administration: |Gas exchange, impaired, related to acidosis or alkalosis |

|Obtain complete health history including allergies, drug history and |Fluid volume excess, related to bicarbonate |

|possible drug interactions |Knowledge, deficient, related to proper use of sodium bicarbonate |

|Assess for presence/history of metabolic acidosis or alkalosis, | |

|cardiovascular disease, decreased renal function, peptic ulcer disease| |

|Obtain vital signs | |

|Monitor ABGs | |

|Planning: Patient goals and Expected Outcomes |

|Patient will: |

|Demonstrate reversal of symptoms of acidosis or alkalosis |

|Demonstrate pH between 3.5-5.3, and sodium level between 135-145 |

|Demonstrate understanding of proper uses/application of sodium bicarbonate products |

|Implementation |

| Interventions and (Rationales) | Patient Teaching/Discharge Planning |

|Monitor for alkalosis. (Indicates drug effectiveness.) |Advise patient and caregiver regarding symptoms of alkalosis: |

| |irritability, confusion, cyanosis, slow respirations, irregular pulse,|

| |muscle twitching. |

|Monitor for metabolic acidosis. (Sodium bicarbonate is used to |Advise patient and caregiver regarding symptoms of acidosis: |

|neutralize acidosis.) |sleepiness, coma, disorientation, dizziness, headache, seizures, |

| |hypoventilation. |

|Monitor respirations, pulse, lung sounds, fluid balance, pH, ABGs. |Advise patient that frequent vital signs checks and lab studies will |

| |be performed. |

|Monitor for decreased renal function. (Drug will not be excreted, |Advise patient that intake and output balance, pH of urine, daily |

|leading to metabolic alkalosis.) |weight will be done. |

|Monitor for hyponatremia: elevated blood pressure, cold, clammy skin, |Advise patient regarding symptoms of hyponatremia and to notify |

|anorexia, vomiting, diarrhea, abdominal cramps lethargy, fatigue, |health care provider/health care provider if he/she notes any of |

|confusion, headache, seizures, coma, tremors |symptoms listed in previous column |

|Monitor for hypokalemia. |Advise patient regarding symptoms of hypokalemia including muscle |

| |cramps, nausea, irregular heart rhythm and to report symptoms 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 POTASSIUM CHLORIDE

|Assessment |Potential Nursing Diagnosis |

|Prior to administration: |Falls, risk for, R/T adverse reactions to medication |

|Obtain complete health history including allergies, drug history and |Knowledge, deficient, proper use of medication, R/T no previous |

|possible drug interactions. |exposure |

|Assess for presence/history of severe renal disease, hypokalemia, |Skin integrity, impaired, risk for, R/T extravasation at IV site |

|hyperkalemia, dehydration, acidosis or alkalosis, cardiac dysrhythmias|Therapeutic regimen management, ineffective, R/T lack of understanding|

| |regarding other medication/food use |

| |Urinary elimination, impaired, decreased urinary output, R/T |

| |medication use |

|PLANNING: PATIENT GOALS and EXPECTED OUTCOMES |

|Patient will: |

|Remain free of physical injury |

|Demonstrate knowledge of drug therapy, side effects, and adverse reactions |

|Maintain intact skin integrity |

|Demonstrate understanding of possible drug interactions |

|Maintain urinary elimination within normal range |

|Implementation |

| Interventions and (Rationales) | Patient Teaching/Discharge Planning |

|Monitor serum potassium levels (indicates effectiveness of therapy) |Instruct patient to be aware of symptoms of hyperkalemia: nausea, |

| |abdominal cramping, oliguria, weakness, changes in heart rate, |

| |numbness or tingling of arms or legs |

|Monitor kidney function. (Damaged kidneys are unable to excrete normal|Advise patient and caregiver regarding the importance of kidney |

|amounts of potassium, leading to hyperkalemia.) |function tests and of complete disclosure of past medical history. |

|Monitor diet for excessive foods containing potassium. (There is a |Instruct patient to: |

|risk for hyperkalemia resulting in cardiac dysrhythmias. Patient |Avoid use of salt substitute without approval of health care provider |

|receiving potassium supplements should avoid use of salt substitute |Avoid increasing potassium rich foods while taking a potassium |

|since most use potassium in place of sodium.) |supplement, including bananas, oranges, orange juice, broccoli, |

| |carrots, brussel sprouts, etc. |

|Monitor for overdose. (Patient is at risk for cardiac dysrhythmias.) |Advise patient and caregiver that frequent blood studies will be done |

| |so early hyperkalemia will be identified. |

|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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