Prototype DRUG: Cyclobenzaprine (Cycloflex, Flexeril)
NURSING Process FOCUS: Patients Receiving Cyclobenzaprine (Cycloflex, Flexeril)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Pain related to disease process |
|Assess for pain, muscle stiffness, and mobility (initially and |Impaired Physical Mobility related to pain |
|throughout therapy) |Knowledge Deficit related to action and effects of medication |
|Obtain complete medical history, especially renal, liver, neurological| |
|diseases including blood studies: | |
|CBC, WBC with differential for blood dyscrasias and liver function | |
|studies | |
|Obtain patient’s drug history to determine possible drug interactions | |
|and allergies | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|State relief of pain and spasms |
|Report an increase in range of motion of affected body part |
|State expected outcomes of drug therapy and list reportable side effects |
|Implementation |
| Interventions and (Rationales) |Patient Education/Discharge Planning |
|Observe for side effects such as drowsiness, dry mouth, dizziness, |Instruct the patient to: |
|nausea, vomiting, faintness, headache, nervousness, diplopia, and |Not drive or operate dangerous machinery when taking muscle relaxants. |
|urinary retention. |Take medication with food to decrease gastrointestinal upset. |
| |Report signs of urinary retention such as feeling of fullness, |
| |distended abdomen, and discomfort. |
| |Use frequent mouth rinses and sugarless candy or gum if expereincing |
| |dry mouth |
|Monitor serum liver enzymes levels. Report elevation (Medication may |Instruct patient concerning the importance of having lab work done |
|cause serious liver damage) | |
|Monitor length of time on drug. (Drug should be tapered to avoid |Inform the patient that the muscle relaxants should not be taken for |
|rebound spasms.) |more than 3 weeks and should not be abruptly stopped. |
|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 Dantrolene Sodium (Dantrium)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Pain related to disease process |
|Assess for pain, muscle strength, and spasticity (initially and |Impaired Physical Mobility related to pain |
|throughout therapy) |Self Care Deficit related to Immobility and pain |
|Obtain complete medical history, especially cardiac, renal, liver, |Knowledge Deficit related to action and effects of medication |
|neurological diseases including blood studies: CBC, WBC with | |
|differential for blood dyscrasias and liver function studies | |
|Obtain patient’s drug history to determine possible drug interactions | |
|and allergies | |
|Assess ability to self administer medication | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|State relief of pain and spasticity |
|Report an increase in range of motion and dexterity of affected body part |
|State expected outcomes of drug therapy and list reportable side effects |
|Implementation |
| Interventions and (Rationales) |Patient Education/Discharge Planning |
|Observe for side effects such as muscle weakness, drowsiness, dry mouth, |Instruct the patient to: |
|dizziness, nausea, diarrhea, tachycardia, erratic blood pressure, |Report side effects. |
|photosensitivity, and urinary retention. |Not drive or operate dangerous machinery when taking muscle |
| |relaxants. |
| |Take medication with food to decrease gastrointestinal upset. |
| |Report signs of urinary retention such as feeling of fullness, |
| |distended abdomen, and discomfort. |
| |Use frequent mouth rinses, sips of water, and sugarless candy or gum|
| |may help with dry mouth |
| |Use sunscreen |
|Monitor for muscle rigidity, pain, range of motion, and dexterity (to |Inform patient to report changes in spasticity, range of motion, |
|monitor effectiveness of medication). |dexterity, and pain levels to order to determine effectiveness. |
|Monitor serum liver enzymes levels. Report elevation. |Instruct patient concerning the importance of having lab work done |
| |because medication may cause serious liver damage. |
|Monitor length of time on drug. (Drug should be tapered over a one to two|Inform the patient that the muscle relaxants should not be abruptly |
|week period to avoid rebound spasms.) |stopped. |
|Monitor ability to take medication, assist if necessary. (Spasms may |Instruct family or caregiver about medication and proper |
|inhibit ability of patient to self-administer medication) |administration in case patient is unable to self-medicate. |
|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 Calcium Supplements
|ASSESSMENT |POTENTIAL NURSING DIAGNOSES |
|PRIOR TO ADMINISTRATION: |■ Risk for Injury, related to loss of bone mass and side effects of |
|■ Obtain complete health history including allergies, drug |drug |
|history, and possible drug interactions. |■ Deficient Knowledge, related to drug therapy |
|■ Obtain baseline ECG. | |
|■ Obtain baseline vital signs, especially apical pulse for rate | |
|and rhythm, and blood pressure. | |
|■ Obtain lab work to include CBC and electrolytes, especially | |
|calcium. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|■ Have normal serum calcium levels (8.5–11.5 mg/dl) |
|■ Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions, and measures to take to |
|decrease any side effects |
|■ Immediately report side effects and adverse reactions |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|■ Monitor electrolytes throughout therapy. (Calcium and phosphorus|■ Teach patient of importance of routine lab studies, so deviations |
|levels tend to vary inversely. Low magnesium levels tend to |from normal can be corrected immediately. |
|coexist with low calcium levels.) | |
|■ Monitor for signs and symptoms of hypercalcemia. (Overtreatment |■ Instruct patient to report signs or symptoms of hypercalcemia: |
|may lead to excessive serum calcium levels.) |drowsiness, lethargy, weakness, headache, anorexia, nausea and |
| |vomiting, increased urination, and thirst. |
|■ Initiate seizure precautions for patients at risk for |■ Teach patient to be aware of signs of hypocalcemia, such as |
|hypocalcemia. (Low calcium levels may cause seizures.) |seizures, muscle spasms, facial twitching, and paresthesias. |
|■ Monitor for musculoskeletal difficulties. (Calcium gluconate is |Instruct patient to: |
|used to treat osteoporosis, rickets, osteomalacia.) |■ Take special precautions to prevent fractures |
| |■ Report episodes of sudden pain, joints out of alignment, inability |
| |of patient to assume normal positioning |
|■ Monitor intake and output. Use cautiously in patient with renal |■ Instruct patient to report any difficulty in urination and measure |
|insufficiency. (Calcium is excreted by the kidneys.) |I&O. |
|■ Monitor cardiac functioning. (Possible side effects may include |■ Inform patient to recognize and report palpitations or shortness of|
|short QT wave, heart block, hypotension, dysrhythmia, or cardiac |breath to healthcare provider. |
|arrest with IV administration.) | |
|■ Monitor injection site during intravenous administration for |■ Instruct patient to report any pain at IV site. |
|infiltration. (Extravasation may lead to necrosis.) | |
|■ Monitor diet. (Consuming calcium-rich foods may increase effect |■ Advise patient to: consume calcium-rich foods and avoid zinc-rich |
|of drug. Consuming foods rich in zinc may decrease calcium |foods |
|absorption.) | |
|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 CALCITRIOL (Rocaltrol, Calcijex)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Comfort, impaired, related to effects of calcitriol |
|Obtain complete health history including allergies, drug history |Knowledge, deficient, related to no previous contact with |
|and possible drug interactions |calcitriol |
|Assess for presence/history of hypercalcemia, hypocalcemia, |Therapeutic regimen management, ineffective related to length of |
|vitamin D toxicity, parathyroid dysfunction, decreased renal |time treatment is necessary |
|function. |Urinary elimination, modified, urinary frequency, related to |
|Assess lab values of electrolytes, cholesterol, alkaline |effects of medication |
|phosphatase, calcium and creatinine | |
|Planning: Patient Goals and Expected Outcomes |
|Patient will: |
|Demonstrate increased bone mass |
|Demonstrate knowledge of dietary modifications to include adequate calcium and Vitamin D |
|Demonstrate understanding of drug treatment regimen |
|Remain free of physical discomfort |
|Maintain urinary elimination within normal limits |
|Implementation |
| Interventions and (Rationales) |Patient Education/Discharge Planning |
|*Evaluate patient knowledge about proper storage. (Improper |*Instruct patient to protect medication from light, heat and |
|storage will render calcitriol ineffective.) |moisture. |
|*Monitor diet for adequate calcium and phosphate content. |Advise patient: |
|(Effectiveness of calcitriol therapy depends on adequate daily |to include foods high in calcium and phosphate |
|intake of calcium and phosphate.) |to avoid foods high in sodium or potassium |
| |to increase fluids, unless advised not to by health care provider|
| |symptoms of hypercalcemia, deep bone and flank pain, anorexia, |
| |nausea and vomiting, unusual thirst, constipation, lethargy, |
| |psychosis |
|*Monitor vitamin D intake. (Excessive intake of vitamin D may |*Advise patient to avoid any other sources of vitamin D therapy |
|lead to hypercalcemia.) |while taking calcitriol. |
|*Monitor for side effects/adverse reactions. |*Instruct patient and caregiver to monitor for and report: |
| |headache, weakness, irritability, somnolence, conjunctivitis, |
| |photophobia, rhinorrhea, anorexia, nausea/vomiting, constipation,|
| |weight loss, polydipsia, dry mouth, metallic taste, polyuria, |
| |nocturia, bone and muscle pain, pruritis, decreased libido. |
|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 RALOXIFENE (Evista)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Comfort, impaired, related to side effects of raloxifene |
|Obtain complete health history including allergies, drug therapy |Fluid volume, excess, related to water and sodium retention |
|and possible drug interactions |secondary to medication |
|Assess for presence, history of pregnancy, venous thrombosis, |Knowledge, deficient, related to no previous contact with |
|pulmonary emboli, hnormone use, breast abnormalities |medication |
|Obtain vital signs |Nausea, related to side effects of raloxifene |
|Obtain history of cardiovascular or cerebrovascular disease |Thought processes, disturbed, depression, related to side effects|
| |of medication |
| Planning: Patient Goals and Expected Outcomes |
|Patient will: |
|Demonstrate bone density within normal limits |
|Demonstrate understanding of need for long-term compliance with medication regime |
|Demonstrate understanding of side effects/adverse reactions to report to health care provider |
|Maintain intact thought processes and absence of symptoms of depression |
|Implementation |
| | |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|*Monitor bone density tests and liver function tests. |*Instruct patient to have bone density tests and liver function |
| |tests prior to beginning raloxifene and periodically during |
| |therapy. |
|*Monitor for thromboembolism. (This may indicate need to |*Advise patient about symptoms to report immediately: pain in |
|discontinue therapy.) |calf; sudden dyspnea accompanied by feeling of breathlessness and|
| |impending doom; vision changes. |
|*Monitor weight. (Edema may appear, and cause weight gain.) |Teach patient and caregivers: |
| |how to perform accurate weights |
| |to report weekly weight gain >5 lbs |
|*Monitor activity level. (Prolonged periods of immobility may |Advise patient: |
|increase risk of thromboembolism.) |to avoid sitting in one position for long period |
| |to increase exercise if able and to do weight-bearing exercises, |
| |or to use weights when exercising |
|*Obtain smoking history. (Smoking has an inverse effect on bone |Encourage patient: |
|density.) |to stop smoking |
| |to attend smoking-cessation clinics, courses, etc. |
|*Monitor for hot flashes. (Raloxifene does not prevent, and may |Teach patient: |
|induce, hot flashes.) |that raloxifene does not help decrease severity of hot flashes |
| |measures that may increase comfort: dressing in layers, |
| |explaining physiology of hot flashes, drinking cool liquids, |
| |keeping thermostats turned lower than normal, etc. |
|*Monitor for GU complaints. Patient may experience breast pain, |*Advise patient to increase fluid intake, drink cranberry juice, |
|vaginal burning, or itching, UTI. (Raloxifene exhibits selective |practice careful personal hygiene, wear a supportive bra. |
|estrogen receptor antagonist activity on breast and uterus.) | |
|*Monitor diet for calcium content. (It may be recommended that |*Advise patient to consume foods with high calcium content, |
|patient take a calcium supplement if diet is low in calcium.) |especially milk and milk products, and leafy green vegetables. |
| Evaluation of Outcome Criteria |
|Evalaute the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
NURSING PROCESS FOCUS: Patients Receiving Etidronate (Didronel)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Knowledge, deficient, related to no prior exposure |
|Obtain complete health history including allergies, drug history |Fluid volume, imbalanced, risk for, related to adverse reaction |
|and possible drug interactions |to medication |
|Assess for presence/history of pathologic fractures, |Nausea, related to side effects of medication |
|hypocalcemia, hypercalcemia |Pain, acute, bone, related to adverse reaction to etidronate |
|Assess nutritional status |Therapeutic regimen management, ineffective, related to fact that|
|Obtain lab work to include complete blood count, pH, electrolytes|therapeutic response may take 1-3 months |
|and renal function studies (BUN, creatinine, uric acid) | |
|Assess lab values of calcium and phosphorous | |
| Planning: Patient Goals and Expected Outcomes |
|Patient will: |
|Demonstrate decreased progression of osteoporosis or Paget’s disease |
|Demonstrate decreased risk for pathologic fractures |
|Remain free of side effects or adverse reactions |
|Demonstrate understanding of dietary needs/modifications |
|Maintain adequate fluid volume |
|Implementation |
|Interventions and (Rationales) | Patient Education/Discharge Planning |
|*Monitor for pathologic fractures and bone pain. (Etidronate |*Instruct patient and caregiver to report any sudden bone or |
|causes defective mineralization of newly formed bone.) |joint pain, inability of patient to correctly position self, |
| |swelling over bone or joint. |
|*Monitor for GI problems. (There may be problems with etidronate |*Advise patient and caregiver that new onset nausea or diarrhea |
|absorption if patient has persistent nausea or diarrhea.) |may be symptom of adverse reaction, and to report immediately. |
|*Monitor serum calcium lab values: |Advise patient: |
|Serum calcium levels should be 9-10mg/dl. (Through its inhibition|to have lab studies performed prior to beginning etidronate |
|of bone resorption, etidronate causes blood levels of calcium to |therapy and periodically during therapy |
|fall.) |symptoms of hypocalcemia to report (muscle spasms, facial |
| |grimacing, convulsions, irritability, depression, |
| |psychoses) |
| |symptoms of hypercalcemia to report (increased bone pain, |
| |anorexia, nausea/vomiting, constipation, thirst, lethargy, |
| |fatigue, confusion, depression) |
|*Monitor kidney function, especially creatinine. (Etidronate |*Instruct patient and caregiver to report any urinary changes, |
|cannot be used in patients whose creatinine is >5.) |such as decreased urine production, increased urination. |
|*Monitor BUN, vitamin D, urinalysis, phosphate, magnesium levels.| |
|*Monitor for side effects/adverse reactions including new onset |*Instruct patient what symptoms to be aware of, and to report |
|nausea or diarrhea, metallic taste, constipation, stomatitis, |onset of them immediately. |
|fluid overload, chest pain, dyspnea, seizures. | |
|*Monitor dietary habits. (Diet must have adequate amounts of |*Advise patient to include good food sources of vitamin D, |
|vitamin D, calcium and phosphates.) |calcium and phosphates, including dairy products and green leafy |
| |vegetables. |
|*Monitor compliance with recommended regime. |Advise patient: |
| |that therapy should continue for 6 months maximum, but full |
| |therapeutic response may take 1-3 months |
| |that effects continue several months after drug is discontinued |
| |to avoid vitamins, mineral supplements, antacids and high-calcium|
| |products within 2 hours of taking etidronate. (All |
| |bisphosphonates are poorly absorbed from the GI tract. Measures |
| |should be taken to maximize absorption.) |
| Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcome have been met (see “Planning”). |
Nursing Process Focus:
Patients Receiving HYDROXYCHLOROQUINE SULFATE (Plaquinil Sulfate)
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Fluid volume, deficient, related to diarrhea, anorexia, nausea, |
|Obtain complete health history including allergies, drug history|vomiting secondary to medication |
|and possible drug interactions |Knowledge, deficient, related to no previous contact with this |
|Assess for presence/history of malaria, rheumatoid arthritis, |medication |
|lupus erythematosus |Nutrition, imbalanced, less than body requirements, related to |
|Assess mental status |anorexia, nausea, vomiting, diarrhea secondary to medication |
|Assess GI status |Sensory perception, disturbed, vision and/or hearing, related to |
|Assess CBC, platelets, liver function tests, vision and hearing |adverse reactions of medications |
|tests G6PD deficiency, muscle strength, reflexes, EKG (depressed | |
|T waves, widening of QRS complex) | |
| Planning: Patient Goals and Expected Outcomes |
|Patient will: |
|experience no symptoms of malarial infection, |
|decreased symptoms of rheumatoid arthritis with increased joint mobility, |
|decreased symptoms of lupus erythematosus |
|Demonstrate understanding of necessity of taking hydroxychloroquine exactly as ordered |
|Recognize side effects and need to report |
|Demonstrate understanding of necessity of follow-up appointments |
|Implementation |
| | |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|*Monitor for hepatic problems, actual or potential. (Administer |*Instruct patient to report symptoms of liver dysfunction to |
|medication with caution to patients with decreased liver |health care provider. |
|function, any patient taking hepatotoxic drugs, or alcoholic | |
|patient.) | |
|*Monitor patient and family knowledge regarding expected effects |Advise patient and caregiver: |
|of medication. |that urine may turn rust or brown |
| |to wear sunglasses outside to decrease photo-phobia |
| |to report symptoms of blood dyscrasias (fever, fatigue, bruising,|
| |unusual bleeding |
|*Monitor for symptoms of toxicity. |*Instruct patient to discontinue drug and report to health care |
| |provider immediately if any of following occur: blurred vision |
| |and difficulty focusing, headache, dizziness, urticaria. |
| Evaluation of Outcome Criteria |
|Evalautge the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |
NURSING PROCESS FOCUS: Patients Receiving Colchicine
|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |■ Activity Intolerance, related to joint pain |
|■ Obtain complete health history including allergies, drug history, |■ Disturbed Body Image, related to joint swelling |
|and possible drug interactions. |■ Deficient Knowledge, related to effects and side effects of drug |
|■ Obtain baseline vital signs. |therapy |
|■ Obtain lab work to include CBC, platelets, uric acid levels, renal| |
|and liver function tests, and urinalysis. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|■ Report a decrease in pain and an increase in function in affected joints |
|■ Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions, and measures to take to |
|decrease any side effects |
|■ Immediately report side effects and adverse reactions |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|■ Monitor lab results throughout therapy. (Agranulocytosis and |■ Teach patient importance of routine lab studies, so deviations |
|thrombocytopenia may occur.) Perform Coombs test for hemolytic |from normal can be corrected immediately. |
|anemia. | |
|■ Monitor for signs of toxicity. |■ Instruct patient to report weakness, abdominal pain, nausea, |
| |and/or diarrhea. |
|■ Monitor for signs of renal impairment such as oliguria. Record |■ Instruct patient to report a decrease in urinary output and to |
|intake and output. |increase fluid intake to 3–4 L/day. |
|■ Ensure that medication is administered correctly. |■ Inform patient to take medication on an empty stomach. Medication|
| |should be taken at first sign of gout attack. |
|■ Monitor for pain and mobility. (This is used to assess |■ Teach patient to report an increase or decrease in discomfort and|
|effectiveness of medication.) |swelling. |
|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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