Instruct patient and caregivers: Need for constant monitoring Potential complications of drug therapy

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1 Assessment Prior to administration: Assess patient for chest pain, dysrhythmias, and vital signs (initially and throughout therapy) Obtain complete medical history, including allergies, especially heart block, digitalis toxicity, heart failure, and hypotension. Include blood studies: cardiac enzymes, Digoxin level, electrolytes, CBC. Obtain EKG. Obtain patient s drug history to determine possible drug interactions and allergies. Nursing Process Focus: Patients Receiving Quinidine (Quinidex) Potential Nursing Diagnoses Cardiac Output, Risk for decreased, related to cardiac changes secondary to adverse effects of drug therapy Nutrition, Risk for imbalance related to gastrointestinal disturbances caused by medication Fluid volume, Risk for deficient, related to diarrhea secondary to adverse effect of medication Planning: Patient Goals and Expected Outcomes The patient will: Avoid sudden chest pain and dyspnea Demonstrate a regular heart rhythm with a normal rate Maintain normal bowel pattern Maintain adequate nutritional status Implementation Interventions and (Rationales) Assist in monitoring cardiac rate and rhythm, continuously if administering medication IV. (IV route is used when rapid therapeutic effects are needed therefore constant monitoring is needed to detect any potential serious arrhythmias. May cause cardiotoxicity including asystole because this medication can cause a reduction in conduction throughout all the regions of the heart.) Ensure that EKG is performed. (Changes precede this and show: Increase in PR and QT intervals >50% widening of QRS complex Presence of ventricular tachycardia Presence of ventricular fibrillation) Monitor EKG frequently if medication is given orally. (Medication may cause complete heart block.) Patient Education/Discharge Planning Instruct patient and caregivers: Need for constant monitoring Potential complications of drug therapy Instruct patient and caregivers regarding need for frequent EKG readings.

2 Monitor for diarrhea, which occurs in approximately 1/3 of patients. (Related to the fact that quinidine is related to quinine in structure and action. Diarrhea may be intense.) Monitor for signs of arterial embolism, including sudden chest pain and dyspnea. Report immediately. (Patient is usually placed on coumadin for 3-4 weeks prior to administration of quinidine to prevent arterial embolism, a complication of atrial fibrillation.). Monitor for signs of digoxin toxicity. Report immediately. (Digoxin may be prescribed to prevent quinidine from increasing ventricular rate; however, when used concurrently, quinidine can double digoxin levels.) Determine patient s diet and cultural background. (A diet high in vegetables, citrus fruit and milk may increase the chance of toxicity by delaying the excretion of this medication.) Evaluation of Outcome Criteria Instruct patient to: Take medication with food to minimize gastrointestinal upset, although food may delay absorption of quinidine. Report occurrence of diarrhea to health care provider Instruct patient to immediately report any sudden chest pain or dyspnea to the health care provider. Instruct patient Regarding signs and symptoms of digoxin toxicity and to report immediately To report change in heart rhythm to the health care provider. Not to miss any doses of their medication Instruct patient to avoid adding vegetables, fruit, and milk beyond recommended daily requirements. Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

3 Assessment Prior to administration: Assess for cardiac arrhythmias, including supraventricular tachycardia, ventricular tachycardia, and tachycardia secondary to digoxin toxicity. Assess for chest pain, palpations, vitals signs (initially and throughout therapy). Obtain complete medical history, including, allergies, cardiac, endocrine, depressive disorders. Include the following blood studies: CBC, electrolytes, glucose, cardiac enzymes. Compare EKG at baseline to throughout therapy. Obtain patient s drug history to determine possible drug interactions and allergies. Nursing Process Focus: Patients Receiving Propranolol (Inderal) Potential Nursing Diagnoses Injury, Risk for, related to dizziness secondary to decreased blood pressure Tissue perfusion, Risk for Ineffective, related to decreased cardiac output related to arrhythmia Gas exchange, Risk for Impaired, related to side effects of medication Knowledge deficient, related to drug action and side effects Planning: Patient Goals and Expected Outcomes The patient will: Demonstrate a change in heart rhythm Exhibit a decrease in cardiac arrhythmias Demonstrate expected outcomes of drug therapy and list reportable side effects. Maintain adequate tissue perfusion Implementation Interventions and (Rationales) Monitor for cognitive dysfunction and depression in the elderly, as well as hallucinations and psychosis (more likely with higher doses). (These reactions appear to be related to the lipid solubility of this medication and its ability to cross the blood-brain barrier.) Monitor for proper medication use. (Abrupt discontinuation of medication may cause myocardial infarction, severe hypertension and ventricular arrhythmias because of a potential rebound effect.) Patient Education/Discharge Planning Advise patient regarding potential cognitive side effects and to report any signs of depression to the health care provider. Instruct patient to: Never discontinue the medication abruptly and to take the medication exactly as prescribed. Take the medication even if feeling well Take pulse prior to taking the medication. If pulse is irregular, instruct patient to withhold medication and contact the health care provider immediately

4 Monitor for hypotension. (Medication may lower blood pressure as a result of decreased cardiac output.) Monitor for hypoglycemia. (There is an increased incidence of hypoglycemia in patients with Type I Diabetes Mellitus because this medication may inhibit glycogenolysis). Monitor for diarrhea. (This side effect may be related to the medication s effect on the vascular smooth muscle receptors.) Evaluation of Outcome Criteria Instruct patient to change position slowly to avoid dizziness. Instruct patients with Type I Diabetes Mellitus to: Check blood sugar regularly Report unusually low blood sugar reading to the health care provider. Instruct patient to take medication with food to decrease GI upset. Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

5 Nursing Process Focus: Patients Receiving Amiodarone (Cardarone) Assessment Prior to administration: Assess for ventricular fibrillation, recurrent unstable ventricular tachycardia (initially and throughout therapy). Obtain complete medical history, especially cardiac and liver disease, lung disorders, and eye disorders including blood studies: liver function tests. Obtain baseline eye exam. Obtain patient s drug history to determine possible drug interactions and allergies. Potential Nursing Diagnoses Cardiac output, Risk for decreased, related to cardiac arrhythmias Injury, Risk for, related to adverse effects of medication Gas exchange, Risk for Impaired related to pulmonary damage secondary to side effects of medication Nutrition, Risk for imbalanced related to gastrointestinal distress secondary to side effects of medication Planning: Patient Goals and Expected Outcomes The patient will: Demonstrate ability to measure own pulse. Describe the need to change positions slowly to prevent postural hypotension. Remain free of physical injury Maintain adequate nutrition Demonstrate adequate respiratory function Implementation Interventions and (Rationales) Auscultate lung sounds frequently. (Pulmonary toxicity can occur and may be fatal. Occurs most frequently with oral dosing because absorption is highly variable. Lung tissue which receives good blood flow appears to receive a greater effect from the medication.) Monitor heart rate and rhythm. (May worsen the arrhythmia it is trying to treat. May also cause bradycardia, heart block and cardiac arrest because it slows conduction and increases the refractory period.) Monitor liver enzymes. (Drug may cause liver disease because this medication has a high lipid solubility and is distributed extensively to the liver.) Observe for changes in visual acuity. (May cause optic neuritis which may lead to Patient Education/Discharge Planning Advise patient to notify the health care provider at the first sign of shortness of breath or cough. Instruct patient to report change in heart rate and rhythm to health care provider. Instruct patient regarding signs and symptoms of liver disease such as jaundice, right upper quadrant pain, dark urine and clay colored stool and to report these symptoms to health care provider immediately Instruct patient to report any vision changes to the health care provider

6 blindness. This is caused by corneal immediately. microdeposits.) Monitor blood pressure throughout drug Instruct patient to: therapy. (Hypotension is common early in Change positions slowly to reduce therapy and is related to the dilating action incidence of dizziness of this medication on peripheral blood Monitor blood pressure and report vessels.) abnormalities to the health care provider Observe for occurrence of common side Instruct patient to: effects. (Common side effects include Take medication with food to minimize dizziness, headache, insomnia related to gastrointestinal distress. the antiadrenergic properties of this To cover the skin well when in direct medication. Gastrointestinal distress and sunlight and to wear sunglasses. The photosensitivity also commonly occur). elderly are particularly sensitive to the Report to health care provider. sun. Monitor for concurrent digoxin and Advise patient to: anticoagulant use. Amiodarone increases To report changes in cardiac rhythm digoxin levels in the blood and enhances To report occurrence of abnormal bleeding the actions of anticoagulants. or bruising. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes are met (see Planning ).

7 Nursing Process Focus: Patients Receiving Verapamil (Calan) Assessment Prior to administration: Assess for dysrhythmias, heart rate, and radial pulse (initially and throughout therapy). Obtain complete medical history, including allergies, especially cardiac, renal, liver and respiratory diseases including blood studies: BUN, creatinine, liver function tests. Obtain patient s drug history to determine possible drug interactions and allergies. Potential Nursing Diagnoses Injury, Risk for, related to dizziness secondary to hypotension Gas exchange, Impaired, related to side effects of medication Cardiac output, Risk for Decreased, related to hypotension and bradycardia secondary to side effects of medication Nutrition, Risk for Imbalanced, related to nausea secondary to medication Planning: Patient Goals and Expected Outcomes The patient will: Demonstrate relief of shortness of breath and dizziness Exhibit expected outcome of drug therapy and list reportable side effects Demonstrate blood pressure monitoring and pulse measurement prior to medication. Remain free of physical injury Maintain adequate nutritional status Implementation Interventions and (Rationales) Observe for side effects such as hypotension and bradycardia. (Verapamil causes a decrease in total peripheral resistance which can significantly lower blood pressure. Bradycardia can result because Verapamil slows SA and AV node conduction.) Monitor for signs of pulmonary edema and shortness of breath (related to dilation of the coronary arteries). Monitor serum liver enzymes level (Verapamil may cause an elevation in liver enzymes.) Monitor renal status Monitor BUN and creatinine levels (Verapamil may cause renal damage.) Monitor intake and output. Patient Education/Discharge Planning Instruct patient to take own blood pressure prior to taking medication and if blood pressure is less than 90/60, hold medication and notify the health care provider immediately. Advise patient to notify health care provider of any breathing difficulties. Instruct patient concerning the importance of having lab work done because medications may cause severe liver damage. Instruct patient: Concerning the importance of having lab work done because medications may cause severe renal and kidney damage. To report changes in urinary output to the health care provider.

8 Monitor bowel pattern for occurrence of constipation. (Verapamil often causes nausea and constipation). Observe for signs of digoxin toxicity. (Causes increased digoxin and quinidine levels when used with diltiazem.) Advise patient to: Take medication with food if gastric distress is a problem. Maintain regular bowel habits. Advise patient to increase fruits and fiber in the diet. Instruct patient to notify health care provider of all medications taken and to notify health care provider if there is a change in cardiac rhythm Evaluation of Outcome Criteria Evaluate effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

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