Nursing Process Focus: Patients Receiving Chlorpromazine (Thorazine) Potential Nursing Diagnoses Ineffective Therapeutic Regimen Management Risk for Activity Intolerance, related to side effect of drug Deficient Knowledge, related to drug action and side effects Constipation, related to decreased intestinal motility Risk for Injury, related to drug effects Planning: Patient Goals and Expected Outcomes Assessment Prior to administration: Obtain complete health history, especially of mental illness, respiratory, gastrointestinal, genitourinary disorders, alcohol and illegal drug use. Include blood studies: electrolytes, CBC, BUN, creatinine, HCG levels if indicated, and drug screens (for use of illegal drugs.) Obtain patient s drug history to determine possible drug interactions and allergies. The patient will: Experience relief of positive symptoms of schizophrenia, and relief of manic symptoms in patients with schizo-affective disorder. 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. Abstain from alcohol and illegal drug use. Immediately report any occurrence of any adverse reactions. Implementation Interventions and (Rationales) *Monitor for EPS and NMS. Medications may be available to treat EPS. (Presence of EPS may be sufficient reason for patient to discontinue chlorpromazine; NMS is lifethreatening and must be reported and treated immediately.) *Monitor for cheeking, hoarding or sharing medication. Observe patient closely for noncompliance. (If therapeutic results are not seen, patient may not be taking medication as ordered, even though he/she may appear to be taking it.) *Observe for side effects such as orthostatic hypotension, constipation, anorexia, GU problems, respiratory changes, visual disturbances. (These side effects are caused by the anticholinergic effects of chlorpromazine.) Patient Education/Discharge Planning Teach patient and family to: Recognize tardive dyskinesia, dystonia, akathesia, pseudoparkinsonism. Recognize and seek treatment immediately for elevated temperature, unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and incontinence. Teach patient/family: Importance of taking medication exactly as ordered, and not sharing it with anyone. How to check to be sure patient has swallowed medication. *Inform patient that impotence, gynecomastia, amenorrhea or enuresis may occur. Instruct patient: To change position and arise slowly. Do not to drive a car until he/she is stabilized on chlorpromazine and sedating effects are known.
*Monitor for use of medication. (Medication must be gradually withdrawn over a 2-3 week time, or patient may experience nausea/vomiting, dizziness, tremors, or dyskinesia.) *Monitor patient for respiratory depression, laryngospasm, dyspnea. *Monitor for caffeine use. (Caffeine will cause a decreased therapeutic response of chlorpromazine.) *Monitor patient s environment. (Chlorpromazine may cause patient to perceive brownish discoloration of objects or photophobia. Chlorpromazine may also interfere with the body s ability to regulate body temperature.) *Observe for evidence of alcohol/illegal drug use. (The patient may use alcohol/illegal drugs as means as coping with symptoms of psychosis.) To report vision changes. To comply with required laboratory tests as ordered, e.g. Thorazine levels, electrolytes, CBC, BUN, and creatinine. To increase roughage in diet, increase fluids, and increase exercise to decrease or avoid constipation. Instruct patient: *To continue taking the medication as ordered, even if no therapeutic benefits are felt. *That it may take 6 weeks-6 months for full therapeutic benefits. *Instruct patient that if any respiratory symptoms occur, their health care provider must be notified. *Instruct patient to avoid caffeine in common products containing caffeine, including: coffee, tea, carbonated beverages, and chocolate. Instruct patient to: *Wear dark glasses to avoid discomfort from photophobia. *Avoid temperature extremes. *Instruct the patient to refrain from alcohol/illegal drug use. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).
Assessment Prior to administration: Assess for hallucinations and the level of consciousness both initially and throughout drug therapy. Obtain a complete health and psychological history especially in regards to cardiovascular and neurological disorders. Include blood studies such as CBC, liver enzymes, and electrolytes and obtain an EKG. Obtain the patient s drug history to determine possible drug interactions and allergies. Nursing Process Focus: Patients Receiving Haloperidol (Haldol) Potential Nursing Diagnoses Anxiety, related to disease process Risk for Injury, related to drug effects Deficient Knowledge, related to drug action and side effects Ineffective Therapeutic Regimen Management Planning: Patient Goals and Expected Outcomes Patient will: Report decreased symptoms of psychosis. 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 a medication regimen. Implementation Interventions and (Rationales) *Monitor for EPS and NMS. Medications may be available to treat EPS. (Presence of EPS may be sufficient reason for patient to discontinue medication; NMS is lifethreatening and must be reported and treated immediately.) *Observe for seizures. Use with caution in patients with pre-existing seizure disorders. (Haloperidol decreases seizure threshold.) *Observe for side effects such as severe drowsiness, dizziness, lethargy, headaches, blurred vision, skin rash, diaphoresis, nausea/vomiting, anorexia, diarrhea, and menstrual irregularities. *Monitor for anticholinergic side effects such as dry mouth, constipation, and urinary retention. Patient Education/Discharge Planning Teach patient and family: To recognize tardive dyskinesia, dystonia, akathesia, pseudoparkinsonism. To recognize and seek treatment immediately for elevated temperature, unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and incontinence. Teach patient/family: That seizures may occur. Safety precautions in case a seizure does occur. Instruct the patient: To report side effects. Do not drive or operate dangerous machinery when taking the medication. Teach patient and family: Measures to relieve symptoms such as sugarless hard candy or gum and frequent drinks of water for dry mouth; increased
*Monitor for adverse reactions, including hypotension (use of anti-psychotics causes lowering of blood pressure) OR hypertension (occurs with overdosage), EKG changes, leukopenia, jaundice, altered liver function tests. *Monitor patient s lab tests, observing for leukopenia. *Monitor for alcohol/illegal drug use. (Patients may decide to drink alcohol, so will stop taking the haloperidol. These substances will have an additive CNS depressant effect.) *Discourage caffeine use. *Monitor for cardiovascular changes, including hypotension, tachycardia, and EKG changes. (Haloperidol has fewer cardiotoxic effects than other antipsychotics, and may be preferred for patient with existing CV problems.) *Use with caution in elderly patients. (Older patient may have unusual adverse reactions. They need lower doses and a more gradual dosage increase. Elderly women are at greater risk for developing tardive dyskinesia.) *Encourage smoking cessation. (Heavy smoking causes decreased metabolism of haloperidol, and therefore decreased efficacy.) fluids, fruits and vegetables for constipation; To notify the health care provider if urinary retention occurs. Inform patient/family: That routine lab studies (haloperidol levels, CBC, liver function tests, etc.) and other exams must be done. To change position slowly, in case hypotension occurs, to prevent injury. *Caution the patient to refrain from taking illegal drugs and alcohol. *Caution the patient that combining caffeine with haloperidol will decrease the effectiveness of the drug and likely increase anxiety. Teach patient: That dizziness and falls, especially upon sudden position changes, may indicate CV changes. Safety measures. To have regular medical follow-up. Teach patient/family: To observe for unusual reactions such as confusion, depression and hallucinations and to report them immediately. To observe for symptoms of tardive dyskinesia and report them as soon as they occur. *Advise patient to decrease or discontinue smoking; refer to smoking cessation classes if desired. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).
Assessment Prior to administration: Assess for hallucinations, mental status, dementia, bipolar disorder (initially and throughout therapy). Obtain complete health history, especially psychological, neurologic and blood diseases: including blood studies: CBC, WBC with differential, electrolytes, BUN, creatinine, liver enzymes. Obtain patient s drug history to determine possible drug interactions and allergies. Nursing Process Focus: Patients Receiving Clozapine (Clozaril) Potential Nursing Diagnoses Anxiety, related to disease process Risk for Injury, related to effects of drug Noncompliance, related to side effects of drug Disturbed Sleep Pattern, related to drug effect Deficient Knowledge, related to drug action and side effects Planning: Patient Goals and Expected Outcomes The patient will: Report a reduction of psychotic symptoms, including delusions, paranoia, irrational behavior. 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 to recommended therapy, including medications, psychotherapy, health care provider and lab appointments. Refrain from alcohol, caffeine, smoking, other CNS depressants. Implementation Interventions and (Rationales) *Monitor RBC and WBC counts. If WBC levels drop < 3500, medication will need to be stopped immediately. (Patient may be developing agranulocytosis, which could be life-threatening.) *Monitor for hematologic side effects. (Neutropenia, leukopenia, agranulocytosis, thrombocytopenia may occur, secondary to possible bone marrow suppression caused by clozapine.) *Observe for side effects such as drowsiness, sedation, dizziness, depression, anxiety, tachycardia, hypotension, nausea/vomiting, excessive salivation, urinary frequency or urgency, incontinence, weight gain, muscle pain or weakness, rash, fever. *Monitor for anticholinergic side effects: mouth dryness, constipation, urinary retention. Urinary retention may be corrected only by use of an indwelling catheter. Patient Education and Discharge Planning *Advise patient of the importance of having weekly lab studies done. *Instruct patient to report immediately any sore throat, signs of infection, fatigue, bruising, without apparent cause. *Instruct patient to report side effects to the health care provider. Inform patient that: Mouth dryness and constipation can be decreased with sugarless gum or candy, increased fluids, frequent sips of water,
*Monitor for decrease of psychotic symptoms. Medication is working as it should if patient exhibits more normal thoughts and behaviors. (If patient continues to exhibit symptoms of psychosis, either he is not taking medications as ordered, he is taking an inadequate dose, or he is immune to it and it will need to be discontinued and another anti-psychotic begun.) *Monitor for alcohol use. (Alcohol used concurrently with clozapine will cause increased CNS depression. Patient may decide to stop taking clozapine because he wishes to use alcohol.) *Discourage caffeine use. (Use of caffeinecontaining substances will negate effects of clozapine.) *Encourage smoking cessation. (Heavy smoking may decrease blood levels of clozapine.) *Monitor elderly closely, and give lower doses. (They may be more sensitive to anticholinergic effects.) increased fruits and vegetables in diet. If urinary retention occurs, notify health care provider immediately to prevent complications. Teach patient/family to: Look for more normal behaviors (completing own ADLs, showing more interest in surroundings, more normal sleep patterns, etc.), to notice decrease or absence of symptoms of psychosis, including hallucinations, delusions, paranoia, etc. Contact health care provider if no decrease of symptoms occurs over a six week period. Instruct patient to: Refrain from alcohol use; refer to Alcoholics Anonymous or another support group if indicated. Take medication as ordered; do not stop medication and drink alcohol. *Inform patient of common caffeine-containing products, including coffee, tea, carbonated beverages, chocolate, etc. *Instruct patient to stop or decrease smoking; refer to smoking cessation programs if indicated. *Teach elderly patients ways to counteract anticholinergic effects of medication, while taking into account any other existing medical problems. Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning ).