PROTOTYPE DRUG: Amphotericin B (Fungizone)
NURSING PROCESS FOCUS: Patients Receiving Amphotericin B (Fungizone, Abelcet)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |■ Risk for Injury, related to adverse effects of drug |
|■ Obtain complete health history including allergies, drug |■ Risk for Infection, related to drug-induced leukopenia |
|history, and possible drug interactions. |■ Deficient Knowledge, related to drug therapy |
|■ Obtain a culture and sensitivity of suspected area of infection| |
|to determine need for therapy. | |
|■ Obtain baseline vital signs, especially pulse and blood | |
|pressure. | |
|■ Obtain renal function including blood tests (CBC, chemistry | |
|panel, BUN, and creatinine). | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|■ Report fewer symptoms of fungal infection |
|■ Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions |
|Immediately report effects such as fever, chills, fluid retention, dizziness, or decrease in urine output |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|■ Monitor vital signs, especially pulse and blood pressure, |■ Advise patient to report dizziness, shortness of breath, heart |
|frequently during and after infusion. |palpitations, or faintness immediately. |
|(Cardiovascular collapse may result when drug is infused too | |
|rapidly, which is caused by the drug binding to human cytoplasmic| |
|sterols.) | |
|■ Monitor kidney function, including intake and output, |Instruct patient to: |
|urinalysis, and periodic blood work. |■ Keep all laboratory appointments for blood work (CBC, |
|(Amphotericin B is nephrotoxic. This medication is excreted in |electrolytes every 2 weeks; BUN, creatinine weekly) |
|the urine and causes significant electrolyte loss from the |■ Keep an accurate record of intake and output |
|kidneys.) |■ Drink at least 2.5 L of fluids daily |
| |■ Report a decrease in urinary output, change in the appearance |
| |of urine, or weight gain or loss |
|■ Monitor for GI distress. |Instruct patient to: |
| |■ Take an antiemetic prior to drug therapy, if needed |
| |■ Report GI distress such as anorexia, nausea, vomiting, extreme |
| |weight loss, and headache |
|■ Monitor for fluid overload and electrolyte imbalance. |■ Advise patients with any form of cardiac disease to report any |
|(Patients with cardiac disease are at high risk.) |palpitations, chest pain, swelling of extremities, and shortness |
| |of breath. |
|■ Monitor for signs/symptoms of toxicity and hypersensitivity. |Instruct patient to report the following: |
| |■ IV: malaise, generalized pain, confusion, depression, |
| |hypotension tachycardia, respiratory failure, evidence of |
| |otoxicity such as hearing loss, tinnitus, vertigo, and unsteady |
| |gait |
| |■ Topical: irritation, pruritus, dry skin, redness, burning, and |
| |itching |
|■ Monitor IV site frequently for any signs |■ Advise patient to report any pain at the IV site. |
|of extravasation. (Medication is irritating to | |
|the vein. Use a central line if possible.) | |
|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 Nystatin (Mycostatin)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Injury, Risk for (rash) related to adverse effects of medication |
|Obtain complete health history including allergies, drug history and |Altered Nutrition: Less than body requirements, Risk for, related to |
|possible drug interactions. |nausea and vomiting secondary to drug therapy |
|Obtain a culture and sensitivity test of suspected area of infection to|Knowledge, Deficient related to drug therapy and side effects |
|determine need for therapy | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will |
|Exhibit a clearing of fungal infection. |
|Demonstrate an understanding of the intended effect of drug therapy and the lifestyle modification necessary for that effect. |
|Follow instructions necessary for completion of drug therapy |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor for possible side effects or hypersensitivity. |Instruct patient to report any burning, stinging, dryness, itching, and |
| |local irritation to their health care provider. |
|Monitor for proper use of the different formulations of this |Advise patient to: |
|medication. |“Swish and swallow” the oral suspension. Make sure patient understands |
| |the importance of coating all mucous membranes before swallowing |
| |medication |
| |Allow troche to dissolve completely. Do not chew or swallow. Inform |
| |patient that for troche it may take 30 minutes for it to completely |
| |dissolve |
| |Remove dentures prior to using the oral suspension. |
|Observe for proper application of dressings. (Occlusive dressings |Instruct patient to: |
|increase the moisture in these areas and encourage development of |Apply dressings properly |
|additional yeast infections.) |Avoid wearing tight fitting undergarments if using ointment in the |
| |vaginal or groin area. |
|Strictly follow standard precautions when applying medication to |Teach patient to |
|affected areas (to decrease spread of infection). |Clean affected area daily |
| |Apply medication with a glove |
| |Wash hands properly and keep nails clean |
| |Change socks daily if rash is on feet |
|Monitor for alcohol use. (Increases the risk of side effects such as |Instruct patient to avoid alcohol during drug therapy. |
|nausea vomiting and an increase in blood pressure with concurrent use.)| |
|Monitor for effectiveness of medication. (As evidenced by a |Instruct patient to: |
|decrease/elimination of fungus.) |Report spread of affected area |
| |Use medication as ordered. May need to use for several weeks |
|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 Metronidazole (Flagyl)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |■ Risk for Injury, related to dizziness secondary to side effect |
|■ Obtain complete health history including allergies, drug |of drug |
|history, and possible drug interactions. |■ Risk for Fluid Volume Imbalance related to nausea and vomiting |
|■ Obtain results from serologic studies, stool samples or |secondary to side effect of drug |
|cultures of the suspected area of infection to determine the need| |
|for therapy. | |
|■ Obtain baseline vital signs, especially pulse and blood | |
|pressure. | |
|■ Obtain complete blood count. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|■ Report decreased signs and symptoms amebic or other infection |
|■ Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions |
|■ Immediately report effects such as seizures, numbness in limbs, nausea, vomiting, hives, or itching |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|■ Monitor complete blood count periodically. (The drug may cause |■ Instruct patient to notify the healthcare provider of fever or |
|leukopenia.) |other signs of infection. |
|■ Encourage treatment of sexual partner. (Asymptomatic |■ Instruct patient that simultaneous treatment of a sexual |
|trichomoniasis in the male is a frequent source of reinfection.) |partner is necessary. |
|■ Monitor use of alcohol. |Instruct patient to: |
|(Metronidazole interferes with the metabolism of alcohol.) |■ Abstain from alcohol including any OTC medication that contains|
| |alcohol (liquid cough and cold products) |
| |■ Report side effects such as cramping, vomiting, flushing, and |
| |headache which may result with alcohol use |
|■ Monitor CNS toxicity. |■ Instruct patient to immediately report seizures, numbness of |
|(High doses may cause seizures and peripheral neuropathy possibly|limbs, nausea, and vomiting. |
|related to the medication’s distribution into the CSF.) | |
|■ Monitor for allergic reactions. |■ Instruct patient to immediately report hives and itching, rash,|
| |flushing, fever, and/or joint pain. |
|■ Monitor for gastrointestinal distress. |Instruct patient to: |
|(This is the most common adverse effect.) |■ Take medication with food to decrease gastrointestinal distress|
| |■ Recognize that medication may cause a metallic taste in the |
| |mouth |
|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 Zidovudine (Retrovir)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration |Infection, Risk for related to decreased CD4 count |
|Obtain complete health history including allergies, drug history and |Injury, Risk for (dizziness) related to adverse effects of drug therapy|
|possible drug interactions. |Pain, Risk for (Headache) related to adverse effects of drug therapy |
|Assess for presence or history of viral infection |Tissue perfusion, Risk for Ineffective related to bone marrow |
|Assess complete blood count, CD4 count, liver and kidney function |depression secondary to adverse effects of drug therapy |
|Obtain history of sensitivity to Zidovudine | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Remain free of side effects, including headache, insomnia, confusion, petechiae, nausea, vomiting, rash, fever and muscle pain. |
|Demonstrate understanding of all lifestyle modifications necessary for successful completion of drug therapy |
|Maintain adequate tissue perfusion |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Observe for signs and symptoms of infection or bleeding. (Patient may|Advise patient: |
|develop granulocytopenia or thrombocytopenia.) |That medication may decrease the level of HIV infection in the blood |
|Monitor vital signs (especially temperature). |but will not prevent transmitting the disease |
| |To use barrier protection during sexual activity |
|Monitor use of acetaminophen. (Concurrent use of acetaminophen may |Instruct patient not to use acetaminophen while on drug therapy and |
|increase chance of bone marrow depression.) |warn that acetaminophen is often used with cold product preparations |
|Monitor weight. (Weight gain may indicate positive effect of drug |Advise patient to: |
|therapy and absence of GI distress.) |Take medication 1 hour before meals. |
| |Report GI distress to the health care provider |
|Monitor intake and output (may cause renal dysfunction) |Instruct patient to report changes in urinary output to the health care|
| |provider. |
|Monitor complete blood count and CD4 counts weekly (to evaluate |Advise patient to keep all laboratory appointments. |
|effectiveness of therapy). | |
|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 Acyclovir (Zovirax)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration |Infection, Risk for related to ineffective response to drug therapy |
|Obtain complete health history including allergies, drug history and |Nutrition, Risk for Imbalanced: less than body requirements related to |
|possible drug interactions |nausea, vomiting and diarrhea secondary to adverse effects of drug |
|Assess for presence/history viral infections |therapy |
|Assess renal function, complete blood count, viral culture, and vital|Injury, Risk for (seizures) related to adverse effects of drug therapy |
|signs |Knowledge Deficient, related to drug therapy and side effects |
|Assess for herpes simplex infection | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Demonstrate understanding of intended effects of drug therapy and the lifestyle modifications necessary to achieve intended drug effect. |
|Maintain weight within expected levels |
|Remain free of physical injury |
|Remain free of side effects including headache, confusion, seizures, flank pain, hematuria, rash and petechiae. |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Monitor complete blood count periodically. (Drug may cause |Advise patient to: |
|thrombocytopenic purpura or hemolytic uremic syndrome.) |Report occurrence of unusual bleeding and bruising to the health care |
|Monitor vital signs (especially temperature). |provider |
| |Increase fluid intake while on drug therapy to prevent dehydration |
| |Refrain from sexual activity until no symptoms of herpes infection |
| |remains |
| |Inform patient that: |
| |Recurrences of herpes simplex infection may be precipitated by stress, |
| |trauma or other physical illness |
| |Drug therapy is most effective when begun soon after the start of |
| |symptoms |
|Monitor renal status. (Acute renal failure may result if administered|Instruct patient: |
|with other nephrotoxic drugs.) |To report all medications taken to the health care provider |
| |To report changes in urinary output |
|Monitor intake and output. (Medication may cause anorexia and |Advise patient: |
|stomatitis.) |To report symptoms of ulcerations of the mouth to the health care |
| |provider |
| |To report inability to tolerate meals |
|Observe for evidence of GI distress. |Advise patient that medication may be taken with food to decrease |
| |gastrointestinal distress. |
|Observe IV site closely and stop infusion at first sign of |Instruct patient to immediately report burning, pain at the IV site to |
|infiltration. (Drug causes severe inflammation at the sit of |the health car provider. |
|infiltration.) | |
|Periodically monitor BUN, serum creatinine and urinalysis. (Renal |Instruct patient to report changes in urinary output to the health care|
|dysfunction may occur.) |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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