Nursing Process Focus: Patients Receiving Phenelzine (Nardil)

Transcription

1 Assessment Prior to administration: Obtain complete health history including allergies, neurological, cardiac, renal, biliary, and mental disorders including blood studies: CBC, platelets and liver enzymes. Obtain patient s drug history to determine possible drug interactions and allergies. Obtain 24 hour dietary history to identify tyramine containing foods ingested recently. Assess neurological status, including identification of recent mood and behavioral patterns. Nursing Process Focus: Patients Receiving Phenelzine (Nardil) Potential Nursing Diagnoses Chronic Sorrow, related to depressive state Disturbed Thought Processes, related to effects of drug therapy Impaired Adjustment, related to inadequate drug effectiveness Deficient Knowledge, related to drug action and side effects Risk for Suicide, related to inadequate drug effectiveness Hopelessness, related to emotional state Planning: Patient Goals and Expected Outcomes The patient will Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Implementation Interventions and (Rationales) *Monitor vital signs, especially pulse and blood pressure. (Phenelzine may cause orthostatic hypotension.) *Monitor cardiovascular status. *Observe for hypertensive crisis and signs of impending stroke or M.I.: severe headache, dizziness, paresthesias, bradycardia, tachycardia, nausea/vomiting, diaphoresis. *Monitor neurological status. *Observe for changes in LOC and seizures. Use with caution in epilepsy. (MAOIs may reduce the seizure threshold.) *Monitor mental and emotional status. Patient Education/Discharge Planning *Immediately report any change in sensorium particularly impending syncope. *Avoid abrupt changes in posture; rise slowly from prolonged periods of sitting/lying down. *Monitor vital signs (especially blood pressure) ensuring proper use of home equipment. *Consult the health care provider regarding "reportable" blood pressure readings (e.g. "lower than 80/50). *Instruct patient to immediately report severe headache, dizziness, paresthesias, bradycardia, tachycardia, nausea/vomiting, diaphoresis. *Instruct patient to report significant changes in neurological status, such as seizures, extreme lethargy, slurred speech, disorientation or ataxia. Interview patient regarding suicide potential;

2 *Observe for suicidal ideation. Therapeutic benefits may take 2-6 weeks. *Monitor kidney and liver function. Observe for signs of hepatic toxicity. Monitor laboratory blood work such as platelets, PT, PTT, and liver enzymes. *Assess urinary output and edema in feet/ankles. (Medication is excreted through the kidneys. Long term use may lead to renal dysfunction.) *Monitor CBC, BUN, creatinine, and urinalysis. Obtain a "no-self harm" verbal contract from the patient. Instruct the patient to immediately report dysphoria or suicidal impulses. report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness or distention, or change in color of stool. adhere to a regular schedule of laboratory testing for liver function as ordered by the health care provider. report changes in urination, flank pain or pitting edema immediately. *Ensure patient safety. (Dizziness caused by postural hypotension increases the risk of fall *Call for assistance before getting out of bed or injuries.) attempting to ambulate alone. *Raise bed rails. Place call bell within *Avoid driving or other activities requiring patient's reach. mental alertness or physical agility until blood pressure is stabilized and effects of the medication are known. *Wear/carry identification stating taking MAOI. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

3 Assessment Prior to administration: Obtain complete health history including allergies, neurological, cardiac (including recent MI) renal, biliary, and mental disorders including EKG and blood studies: CBC, platelets, BUN, creatinine, liver enzymes and urinalysis. Obtain patient s drug history to determine possible drug interactions and allergies. Assess neurological status, including seizure activity and identification of recent mood and behavioral patterns. Nursing Process Focus: Patients Receiving Imipramine (Tofranil) Potential Nursing Diagnoses Chronic Sorrow, related to disease process Disturbed Thought Processes, related to effects of drug Impaired Adjustment, related to inadequate drug therapy Deficient Knowledge, related to drug action and side effects Risk for Suicide, related to inadequate drug therapy Urinary Retention, related to side effects of drug Planning: Patient Goals and Expected Outcomes The patient will: Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Maintain normal urinary flow. Implementation Interventions and (Rationales) *Monitor vital signs especially pulse, and blood pressure. (Imipramine may cause orthostatic hypotension.) *Monitor cardiovascular status. *Observe for hypertension and signs of impending stroke or M.I. and heart failure. Use with caution in cardiac patients. *Monitor neurological status. *Observe for somnolence and seizures. (Imipramine causes somnolence related to CNS depression. Use with caution in epilepsy. Imipramine may reduce the seizure Patient teaching/discharge planning *Immediately report any change in sensorium particularly impending syncope. *Avoid abrupt changes in posture; rise slowly from prolonged periods of sitting/lying down. *Monitor vital signs (especially blood pressure) ensuring proper use of home equipment. *Consult the health care provider regarding "reportable" blood pressure readings (e.g. "lower than 80/50). *Instruct the patient to immediately report severe headache, dizziness, paresthesias, bradycardia, chest pain, tachycardia, nausea/vomiting, diaphoresis or other distressing symptoms. Instruct patient to *Report significant changes in neurological status, such as seizures, extreme lethargy, slurred speech, disorientation or ataxia. *Take dose at bedtime to reduce daytime

4 threshold.) *Monitor mental and emotional status. *Observe for suicidal ideation. Therapeutic benefits are delayed. Out-patients should have no more than a 7-day medication supply. *Monitor for underlying mental disease such as schizophrenia or bipolar disorders. (Imipramine may trigger manic states.) *Monitor renal status and urinary output. (May cause urinary retention due to muscle relaxation in urinary tract. Imipramine is excreted through the kidneys. Impaired kidney function may result in reduced medication clearance and increased serum drug levels. Urinary retention may exacerbate existing symptoms of prostatic hypertrophy.) *Monitor gastrointestinal status. *Observe for abdominal distention. (Muscarinic blockade reduces tone and motility of intestinal smooth muscle, and may cause paralytic ileus.) *Monitor liver function. *Observe for signs and symptoms of hepatic compromise. Monitor blood studies including CBC, differential, platlets, PT, PTT and liver enzymes. *Monitor hematologic status. Observe for signs of bleeding. (Imipramine may cause blood dyscrasias. If given in hyperthyroidism, can cause agranulocytosis.) *Monitor laboratory blood work (see previous box). Use with warfarin may increase bleeding time. *Monitor immune/metabolic status. Use with caution in patients with diabetes mellitus and hyperthryroidism. (Imipramine may either increase or decrease serum glucose.) sedation. *Interview patient regarding suicide potential; obtain a "no-self harm" verbal contract. Instruct the patient: That it may take days before any improvement is noticed, and about a month to achieve full therapeutic effect. To immediately report dysphoria, sleepwake cycle changes or suicidal impulses. Instruct patient or caregiver to: *Measure and monitor fluid intake and output. *Notify the health care provider of the following: edema, dysuria (hesitancy, pain, diminished stream), changes in urine quantity or quality (e.g. cloudy, with sediment) *Report fever or flank pain that may be indicative of a urinary tract infection related to urine retention. *Exercise, drink adequate amounts of fluid and add fiber to the diet to promote stool passage. *Consult the health care provider regarding a bulk laxative or stool softener if constipation becomes a problem. Immediately report Report nausea, vomiting, diarrhea, rash, jaundice, epigastric or abdominal pain, tenderness, or change in color of stool. Adhere to laboratory testing regimen for blood tests and urinalysis as directed. Instruct all patients to: Report excessive bruising, fatigue, pallor, shortness of breath, frank bleeding and/or tarry stools. Demonstrate guiac testing on stool for occult blood. Instruct diabetics to: Monitor glucose level daily. Consult health care provider regarding reportable serum glucose levels (e.g. "less than 70 and more than 140").

5 *Monitor for adverse drug effects and overdosage. Observe for extrapyramidal and anticholinergic effects. (In overdosage, 12 hours of anticholinergic activity is followed by CNS depression. Cardiac dysrthymia may also occur.) *Do not treat overdosage with quinidine, procainamide, atropine or barbiturates. Use of these drugs potentiate cardiac depression. *Monitor visual acuity. Use with caution in narrow-angle glaucoma. (Imipramine may cause an increase in intraocular pressure. Anticholinergic effects may produce blurred vision.) *Ensure patient safety. (Dizziness caused by postural hypotension increases the risk of fall injuries.) *Raise bed rails. Place call bell within patient's reach. *Use cautiously with the elderly or young. (Diminished kidney and liver function related to aging can result in higher serum drug levels, and may require lower doses. Children, due to an immature CNS, respond paradoxically to CNS-active drugs.) Instruct the patient/caregiver: to immediately report involuntary muscle movement of the face or upper body (e.g. tongue spasms), fever, anuria, lower abdominal pain, confusion, anxiety, hallucinations, psychomotor agitation, visual changes, excessively dry mouth, and difficulty swallowing. That mild dry mouth may be relieved by (sugar-free) hard candies, chewing gum and drinking fluids. To avoid alcohol-containing mouthwashes which can further dry oral mucous membranes. Instruct the patient to *Report any disturbing visual changes, headache or eye pain. *Inform eye care professional of imipramine therapy. *Call for assistance before getting out of bed or attempting to ambulate alone. *Avoid driving or other activities requiring mental alertness or physical agility until blood pressure is stabilized and effects of the medication are known. *Instruct the patient/caregiver that the elderly may be more prone to side effects such as hypertension and dysrythmias. Children on imipramine for nocturnal enuresis may experience mood alterations. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

6 Assessment Prior to administration: Obtain complete health history including allergies, neurological, psychological, cardiac, renal, and liver disorders (including recent history of seizures or suicidal ideation) and including blood studies: glucose, BUN, creatinine, electrolytes, liver function tests. Obtain patient s drug history to determine possible drug interactions and allergies Nursing Process Focus: Patients Receiving Fluoxetine (Prozac) Potential Nursing Diagnoses Disturbed Body Image, related to weight gain Anxiety, related to drug effect Ineffective Coping, related to inadequate drug therapy Deficient Knowledge, related to drug action and side effects Risk for Suicide, related to early drug therapy Powerlessness, related to depressive state Planning: Patient Goals and Expected Outcomes The patient will: Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate a decrease in anxiety (e.g. ritual behaviors). Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Implementation Interventions and (Rationales) *Observe for Serotonin Syndrome (SS), a medical emergency. (Serotonin Syndrome is possible at high doses, and especially combined with MAOIs.) *For suspected SS, stop the drug and initiate supportive care: monitor ALL vital signs, including EKG, and respond according to Intensive Care Unit or Emergency Department protocols. Patient Education/Discharge Planning Inform the patient/caregivers: That overdosage may result in serotonin syndrome, which can be life-threatening. To seek immediate medical attention for the following: dizziness, headache, tremor, nausea/vomiting, anxiety, disorientation, hyperreflexia, diaphoresis and fever.

7 *Monitor mental and emotional status. Observe for suicidal ideation. Therapeutic benefits may take a month or more for ideal response. *Monitor for presence of underlying or concomitant mental disorders such as schizophrenia or bipolar disorders. (Fluoxetine may trigger mania.) *Monitor neurological status. *Observe for seizures. Use with caution in epilepsy. (Fluoxetine decreases the seizure threshold.) *Monitor sleep-wake cycle. *Observe for insomnia and/or daytime somnolence. *Monitor kidney and liver function by laboratory tests such as CBC, BUN, creatinine, PT, PTT, liver enzymes and urinalysis. (Fluoxitene is slowly metabolized and excreted, increasing the risk of organ damage. Impaired organ function can further increase drug levels.) *Interview patient regarding suicide potential; obtain a "no-self harm" verbal contract. Instruct the patient: *That it may take days before any improvement is noticed, and about a month to achieve full effect. *To immediately report dysphoria, sleepwake cycle changes or suicidal impulses. *Instruct patient that if seizures occur, stop the drug and contact the health care provider immediately. Instruct the patient with insomnia to: Take the drug very early in the morning to promote normal timing of sleep onset. Avoid driving or potentially hazardous activities until effects of drug are known. If daytime drowsiness persists, medication may be given at bedtime. *Advise the patient to inform the health care provider of the following: nausea, vomiting, diarrhea, rash, jaundice, flank /abdominal pain or tenderness: changes in urinary quantity and quality or in stool color. *Monitor metabolic status. Use with caution Instruct diabetic patients to: in diabetics. (Fluoxitene may cause monitor glucose level daily and consult hypoglycemia initially, and hyperglycemia health care provider regarding reportable with drug withdrawal. Fluoxitene may also serum glucose levels (e.g. "less than 70 cause initial anorexia and weight loss, but and more than 140"). with prolonged therapy may result in weightgain of up to twenty pounds.) weight loss will diminish with continued Instruct the patient that anorexia and therapy. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

8 Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions. Assess mental and emotional status, including any recent suicidal ideation Obtain cardiac history (including) EKG and vital signs; renal, and liver disorders and blood studies: glucose, BUN, creatinine, electrolytes and liver enzymes. Nursing Process Focus: Patients Receiving Lithium (Eskalith) Potential Nursing Diagnoses Risk for Self-Directed Violence Disturbed Thought Processes Disturbed Sleep Pattern Sleep Deprivation (in mania) Risk for Imbalanced Fluid Volume Self-Care Deficit: Dressing/Grooming Planning: Patient Goals and Expected Outcomes The patient will * demonstrate stabilization of mood, including absence of mania and suicidal depression * engage in normal activities of daily living and report subjective improvement in mood * demonstrate understanding of drug action by accurately describing drug effects and precautions. Implementation Interventions and (Rationales) *Monitor mental and emotional status. Observe for mania and/or extreme depression. *Monitor electrolyte balance via lab studies: sodium, potassium, chloride, magnesium and calcium levels. (Lithium carbonate is a natural salt affected by dietary intake of other salts such as sodium chloride. Insufficient dietary salt intake causes the kidneys to conserve lithium, increasing blood levels of the drug.) *Monitor fluid balance. (Lithium causes polyuria by blocking effects of antidiuretic hormone.) *Measure intake and output. Weigh patient daily. (Short-term changes in weight are a good indicator of fluctuations in fluid volume. Excess fluid volume increases the risk of HF; pitting edema may signal HF.) *Monitor renal status. (Lithium may cause degenerative changes in the kidney. Organ impairment increases toxicity.) *Monitor laboratory work: CBC, differential, BUN, creatinine, uric acid and urinalysis. Use with caution in kidney disease. Patient Education/Discharge Planning *Instruct the patient to keep a symptom log to document response to medication. Monitor dietary salt intake; consume sufficient quantities, especially during illness or exertion. Avoid activities that cause excessive perspiration. * Increase fluid intake to 1 to 1.5 L per day. Monitor intake and output. * Limit or eliminate caffeine consumption (caffeine has a diuretic effect that can cause lithium sparing by the kidneys). * Notify health care provider of excessive weight gain or loss, or pitting edema. * Immediately report anuria, especially accompanied by lower abdominal tenderness, distention, headache and diaphoresis. *Inform health care provider of nausea, vomiting, diarrhea, flank pain or tenderness and

9 *Monitor cardiovascular status. (Lithium toxicity may cause muscular irritability resulting in cardiac dysrhythmias or angina.) *Monitor vital signs including apical pulse. *Use with caution in patients with a history of CAD or heart disease. *Monitor gastrointestinal status. (Lithium may cause dyspepsia, diarrhea, or metallic taste.) *Monitor metabolic status. (Lithium may cause goiter with prolonged use. Lithium may cause false-positive results on thyroid tests.) changes in urinary quantity and quality (e.g. sediment). * immediately report palpitations, chest pain or other symptoms suggestive of myocardial infarction. * monitor vital signs ensuring proper use of home equipment. *Instruct patient to take the drug with food to reduce stomach upset and report distressing GI symptoms. *Instruct patient to report symptoms of goiter or hypothyroidism: enlarged mass on neck, fatigue, dry skin or edema. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

10 Nursing Process Focus: Patients Receiving Methylphenidate (Ritalin) Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions. Obtain history of neurological, cardiac, renal, biliary, and mental disorders including blood studies: CBC, platelets, liver enzymes, etc. Assess neurological status, including identification of recent behavioral patterns Assess growth and development Potential Nursing Diagnoses Risk for Delayed Development, related to growth retardation secondary to methylphenidate Delayed Growth and Development, related to increased motor activity, growth retardation secondary to methylphenidate, unsuccessful interpersonal relationships Imbalanced Nutrition: Less than Body Requirements Deficient Knowledge, related to medication use Disturbed Sleep Pattern Planning: Patient Goals and Expected Outcomes Patient will: experience subjective improvement in attention/concentration and reduction in impulsivity and/or psychomotor symptoms ("hyperactivity"). demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Implem Interventions and (Rationales) *Monitor mental status and observe for changes in LOC and adverse effects such as persistent drowsiness, psychomotor agitation or anxiety, dizziness, trembling or seizures. *Use with caution in epilepsy. (Drug may reduce the seizure threshold.) *Monitor vital signs. (Stimulation of the CNS induces the release of catecholamines with a subsequent increase in heart rate and blood pressure.) *Monitor gastrointestinal and nutritional status. (CNS stimulation causes anorexia and elevate BMR, producing weight loss.) Other GI side effects include nausea/vomiting and abdominal pain. entation Patient Education/Discharge Planning *Instruct patient or caregiver to report any significant increase in motor behavior, changes in sensorium or feelings of dysphoria. *Instruct patient to discontinue drug immediately if seizures occur and notify health care provider. * immediately report rapid heartbeat, palpitations or dizziness. * monitor blood pressure and pulse ensuring proper use of home equipment. Instruct patient to * report any distressing GI side effects. * take the drug with meals to reduce GI upset and counteract anorexia; eat frequent small nutrient and calorie dense snacks. * weigh weekly and report losses over 1 lb.

11 *Monitor laboratory tests such as CBC, differential and platelet count. (Drug is metabolized in the liver and excreted by the kidneys; impaired organ function can increase serum drug levels. Drug may cause leukopenia and/or anemia.) *Monitor response to and effectiveness of drug therapy *Monitor growth and development. (Growth rate may stall in response to nutritional deficiency caused by anorexia.) *Monitor sleep-wake cycle. (CNS stimulation may disrupt normal sleep patterns.) * Report shortness of breath, profound fatigue, pallor, bleeding or excessive bruising (signs of blood disorder). *report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness, distention, or change in color of stool (signs of liver disease). *adhere to laboratory testing regimen for blood tests and urinalysis as directed. Schedule regular drug holidays. Not discontinue abruptly as rebound hyperactivity or withdrawal symptoms may occur. Taper the dose prior to starting a drug holiday. Keep a behavior diary to chronicle symptoms and response to medication. Safeguard medication supply due to abuse potential. *Instruct patient or caregiver that reductions in growth rate are associated with methylphenidate usage. Drug holidays may decrease this effect. Instruct patient that: *insomnia may be an adverse reaction. *sleeplessness can sometimes be counteracted by taking last dose no later than 4 p.m.. *drug is not intended to treat fatigue. Warn the patient that fatigue may accompany "wash out." Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).