Nursing Process Focus: Patients Receiving Levodopa (Larodopa)

Transcription

1 Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions. Obtain baseline evaluation of severity of Parkinson s disease to determine medication effectiveness. Obtain baseline vital signs, especially blood pressure and pulse Nursing Process Focus: Patients Receiving Levodopa (Larodopa) Potential Nursing Diagnoses Risk for Falls Deficient Knowledge, related to drug effects and side effects Impaired Mobility Self-Care Deficit: Bathing/Hygiene, Feeding, Toileting, related to disease process Constipation Planning: Patient Goals and Expected Outcomes Patient will Report increased ease of movement and decreased symptoms of Parkinson s disease 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 Adhere to the drug regimen Implementation Interventions and (Rationales) *Monitor vital signs closely when levodopa dose is being adjusted. (Hypotension could occur as result of dose adjustment. Dysrhythmias can occur in patients predisposed to cardiac problems.) *Provide for patient safety. (Orthostatic hypotension may occur.) *Monitor for behavior changes. (Use of levodopa increases risk of depression or suicidal thoughts, as well as causes other mood disturbances such as aggressiveness and confusion.) *Monitor for symptoms of overdose. Muscle twitching and blepharospasm are early symptoms. *Monitor for improved functional status followed by a loss of therapeutic effects (onoff phenomenon), due to changes in dopamine levels that may last only minutes, or days. Usually occurs in patients on long-term levodopa therapy Patient Education/Discharge Planning Instruct patient or caregiver to: *report signs of hypotension, dizziness, lightheadedness, feelings that heart is racing or skipping beats, or dyspnea *have routine EKGs and vital signs taken * to change position slowly and to resume normal activities slowly * how to protect self from falls Instruct patient or caregiver: *watch for and report immediately any signs of changes in behavior or mood *counseling or a support group may help deal with these feelings; assist patient to find such resources if needed *Instruct patient or caregiver to be aware of newly occurring muscle twitching, including muscles of eyelids and to report immediately *Instruct patient or caregiver to report rapid, unpredictable changes in motor symptoms to health care provider immediately, and that this can be corrected with changes in levodopa dosage schedule.

2 *Evaluate diet. (Absorption of levodopa decreases with high protein meals or high consumption of pyridoxine-containing foods.) *Monitor glucose levels in patients with diabetes mellitus. (Loss of glycemic control may occur in diabetic patient.) *Monitor for decreased kidney or liver function. (Decrease in these functions may slow metabolism and excretion of levodopa, possibly leading to overdose or toxicity.) *Monitor for side effects in the elderly. (Elderly patients may experience more rapid and severe side effects, especially those affecting cardiovascular system.) *Monitor for other drug-related changes. (Levodopa may cause urine and perspiration to darken in color, but it is not a sign of overdose or toxicity) Instruct patient to: * take on empty stomach, but food may be eaten 15 minutes after, to decrease GI upset *avoid taking levodopa with high protein meals *avoid high consumption of foods containing vitamin B 6 (pyridoxine) (bananas, wheat germ, green vegetables, liver, legumes). *watch for vitamin B 6 in multivitamins, fortified cereals, and antinauseants, so these products should be avoided *how to read food, OTC medication labels Instruct diabetic patient to: *consistently monitor blood glucose both by self and with periodic lab studies. *report symptoms of hypo- or hyper-glycemia *Advise patient to have liver function tests and kidney function tests prior to beginning levodopa therapy and periodically during therapy *Instruct elderly patients to report any symptoms involving cardiovascular system: changes in heart rate, dizziness, faintness, edema, palpitations *Inform patient that urine may darken and sweat may be dark colored, but not to be alarmed 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, drug history and possible drug interactions. Obtain baseline of severity of Parkinson s symptoms to determine effectiveness. Assess for use of other medications. Obtain lab work to include a complete blood count, liver and renal function studies. Obtain baseline vital signs, especially pulse. Nursing Process Focus: Patients Receiving Benztropine (Cogentin) Potential Nursing Diagnoses Risk for Constipation, related to side effects of drug Risk for Injury, related to effects of drug Risk for Imbalanced Body Temperature Disturbed Sleep Pattern, insomnia or extreme drowsiness related to action of drug Ineffective Therapeutic Regimen Management Urinary Retention, related to side effect of drug Planning: Patient Goals and Expected Outcomes Patient will Experience relief of Parkinson s symptoms or EPS due to anti-psychotic drugs. Immediately report any occurrence of adverse reactions. 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. Maintain compliance with drug regimen. Maintain normal bowel pattern. Implementation Interventions and (Rationales) *Monitor adherence to recommended therapy. Benztropine should be begun with low dose, then gradually increased. *Monitor proper storage of benztropine. *Monitor environmental temperature. (Patient will have decreased ability to tolerate heat, and may develop heat stroke.) *Monitor patient s ability to void, as well as intake and output. (Benztropine can cause urinary hesitation or retention, secondary to its anticholinergic effect.) *Evaluate medication regimen for drugs that interact with benztropine. (Concurrent use of phenothiazines causes increased risk of adverse Patient Education/Discharge Planning *to take benztropine as ordered, unless side effects occur; then notify health care provider. *that it usually takes 2-3 days before desired effect will be noticed. *Advise patient to store benztropine in tightly covered, light-resistant container at moderate room temperature. *Advise patient to avoid strenuous activity in hot weather, to plan rest periods, and to avoid strenuous activity during heat of day to decrease risk of heat stroke. *to report infrequent voiding, or feeling of fullness after emptying the bladder. *to keep a record of intake and output with times of occurrence, and to report imbalance in intake and output. to disclose any history of psychiatric problems or other medication use to all

4 anticholinergic effects; patient will need decreased phenothiazine dose, and close monitoring for worsening symptoms of psychiatric disorder.) *Monitor drug use in elderly. (Increased sedative effects of benztropine may occur and lower doses may be needed.) *Monitor for anticholinergic effects such as dry mouth. *Observe for increased symptoms of Parkinson s or EPS. (If involuntary movements or increased rigidity occur, medication levels may not be therapeutic.) *Monitor for constipation and for signs of paralytic ileus. (This may be caused by decreased GI motility due to drug s anticholinergic effects.) *Observe for unsafe activities. (Benztropine may cause sedation or dizziness.) health care providers to report urinary problems, blurred vision, constipation, dry skin, nausea, vomiting, drowsiness, dysphagia, photophobia *Advise patient to report any drowsiness. *Teach patient measures to use: sugarless hard candy or gum, frequent drinks of water, frequent rinsing of mouth. Review with patient and family: exactly how to take medication. to report increased muscle rigidity, difficulty changing position, muscle spasms or other involuntary movements. Advise patient: to take benztropine after meals to decrease GI irritation. to decrease constipation by increasing fluids, fruits and vegetables, exercise if possible. to report signs of paralytic ileus (abdominal pain, intermittent constipation, abdominal distention, nausea, and vomiting.) Instruct family: to supervise ambulation until response to medication is known Advise patient not to drive until response to medication is known *Monitor for symptoms of overdose. *Advise patient to report immediately: (Some adverse reactions may result from hallucinations, confusion, disorientation, atropine-like toxicity, and may be eliminated by delusions, anxiety, hyperthermia, tachycardia, lowering dose of benztropine.) increased respirations. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).

5 Assessment Prior to administration: Severity of Alzheimer s disease as baseline in order to determine effectiveness. Use of other medications, especially anticholinergics, NSAIDS, carbamazepines dexamethasone phytoin phenobarbital or rifampin. Lab work to include a complete blood count, liver and renal function studies. Baseline vital signs, especially blood pressure and pulse. May cause changes in BP and atrial fibrillation. Nursing Process Focus: Patients Receiving Donepezil (Aricept) Potential Nursing Diagnoses Risk for Injury, related to effects of drug Deficient Knowledge, related to drug action and side effects Impaired Memory, related to ineffective drug therapy Self-Care Deficit: Bathing/Hygiene, Feeding, Toileting, related to disease process Compromised Family Coping, related to ineffective drug therapy Planning: Patient Goals and Expected Outcomes Patient will Experience improved cognitive functioning and memory. 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. Adhere strictly to the recommended treatment. Immediately report any occurrence of any adverse reactions Demonstrate ability to complete ADLs Implementation Interventions and (Rationales) *Investigate any other conditions patient may have that could be mistaken for Alzheimer s disease: electrolyte imbalances, dehydration, psychiatric disorder, adverse reaction to a medication, or other metabolic problem. *Evaluate for COPD or asthma. (Must be used cautiously if they exist; may further decrease diameter of bronchioles, thus decreasing already compromised air exchange.) *Evaluate for cardiovascular problems. (Donepezil may cause bradycardia secondary to vagotonic effects on heart, especially if patient also has conduction abnormalities.) *Monitor for safety. (Donepezil may cause dizziness or bradycardia. See previous section regarding assessing for Patient Education/Discharge Planning *Advise patient/family to have complete medical work-up prior to beginning donepezil therapy. *Instruct patient/family on the importance of complete disclosure of all medical conditions. *Instruct patient/family to be aware of and report any signs of bradycardia, faintness, weakness, fatigue, dizziness, light-headedness. Instruct patient/family: to use caution with ambulation and exercise, and to closely supervise patient.

6 cardiovascular problems.) that as disease progresses, patient will become less aware of safety hazards, and family will have to intervene to keep patient safe. *Monitor for seizures. (Donepezil and any other drug in the category of cholinomimetic medications can cause general seizures. Seizures may also be due to Alzheimer s disease itself.) *Monitor for GI problems. (Donepezil may increase gastric acid secretion, leading to increased risk for developing ulcers with resultant GI bleeding. Donezepil may cause anorexia.) *Monitor for side effects/adverse reactions. *Monitor for worsening of symptoms of Alzheimer s disease. (Donepezil is not effective for every patient who takes it; patient may not be taking medication as ordered, or medication may not have reached therapeutic levels; disease may be progressing despite treatment.) *Monitor for symptoms of overdose: severe nausea/vomiting, sweating, salivation, hypotension, bradycardia, convulsions, increased muscle weakness, including *Teach family measures to take to protect patient during seizure activity. Explain to patient and family: that nausea/vomiting/diarrhea may occur with early therapy but usually resolve in 1-3 weeks of continued therapy. measures to counteract any anorexia. to watch for and immediately report signs of GI bleeding, such as black, tarry stools. Instruct family: on symptoms of CNS and musculoskeletal side effects. that CNS changes may be secondary to disease itself, not medication Instruct patient/family: *correct way to take medication *to notify health care provider if no improvement is noticed within 2 weeks. Teach patient and family: symptoms of cholinergic side effects. patient may need to be hospitalized for treatment of overdose. respiratory muscles Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).