Download Nursing Process Focus: Patients Receiving Nitroglycerin***insert

Nursing Process Focus:
Patients Receiving Atenolol (Tenormin)
Potential Nursing Diagnoses
Assessment
 Tissue perfusion, Risk for Ineffective
Prior to administration:
related to hypotension
 Obtain complete health history including
 Injury, Risk for related to adverse
allergies, drug history and possible drug
effects of medication
interactions.
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Assess EKG for bradydysrhthmias and
heart block
Assess frequency of angina
Apical pulse, and lying and standing
blood pressure
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate an understanding of risks and benefits of drug therapy.
 Maintain adequate tissue perfusion
 Remain free of injury related to adverse effects of medication
Implementation
Interventions and (Rationales)
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Patient Education/Discharge Planning
Monitor blood pressure both lying and
 Instruct patient to change position slowly if
standing (to monitor for orthostatic
orthostatic hypotension occurs.
hypotension).
Monitor blood sugar frequently in patients
 Advise patient to monitor blood sugar
with diabetes mellitus. (Insulin needs may
frequently until accustomed to medication.
be decreased with this medication.)
Observe for changes in heart rate.
 Advise diabetic patients that this
(Medication can mask tachycardia that
medication can mask tachycardia that often
occurs with hypoglycemia)
accompanies hypoglycemia.
Observe for changes in mood. (Decreasing  Advise patient to report any changes in
sympathetic activity may cause decrease in
sexual abilities or depression to health care
sexual desire or ability and depression or
provider.
exacerbate pre-existing conditions.)
Teach patient to:
Monitor effects of exercise on heart rate.
(This drug limits the amount of which the
 Alternate periods of activity with rest
heart rate increases with activity and the
 Discuss effects of medication with
patient will fatigue more quickly with
healthcare provider if they are interfering
activity.)
with activity
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 Diltiazem (Cardizem)
Potential Nursing Diagnoses
Assessment
 Tissue perfusion, Risk for Ineffective
Prior to administration:
related to adverse effects of medication
 Obtain complete health history including
 Injury, Risk for (dizziness, fainting)
allergies, drug history and possible drug
related to hypotension from medication
interactions.
 Knowledge deficient related to new
 Assess blood pressure and pulse
medication regime
 Assess EKG for bradydysrhthmias and
heart block
 Assess frequency of angina
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of risks and benefits of medication
 Maintain adequate tissue perfusion
 Avoid physical injury related to side effects of medication
Implementation
Interventions and (Rationales)
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Monitor neurological status (Headache
may occur related to the arterial dilation
effects of the drug.)
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Monitor intake and output. (Patients with
renal disease should not take some NSAID
and should check with health care provider
before taking OTC medications.)
Take blood pressure in both arms and
while lying standing and sitting (to monitor
for orthostatic hypotension).
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Monitor patient for signs and symptoms of
congestive heart failure: chronic cough,
shortness of breath and weight gain as
CCBs reduce contractility of the heart.
Report immediately. (These symptoms can
indicate pulmonary congestion. a sudden
increase in weight indicates fluid retention
which can result in congestive heart
failure.)
Patient Education/Discharge Planning
Advise patient:
 That his medication may cause headache
 To check with health care provider prior
to the use of any OTC medications to
treat headache
 To avoid use of NSAID during drug
therapy
 Instruct patient on how to monitor/record
intake and output.
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Advise patient that this medication may
cause dizziness therefore the patient
should be careful operating heavy
machinery until the patient has become
accustomed to taking medication.
Advise patient of signs and symptoms of
heart failure (shortness of breath, weight
gain, slow heart beat) and to notify health
care provider if any of these occur.
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 Reteplase (Retevase)
Potential Nursing Diagnoses
Assessment
 Tissue perfusion, Ineffective related to
Prior to administration:
adverse effects of medication
 Obtain complete health history including
 Injury, Risk for (bleeding) related to
allergies, drug history and possible drug
adverse effects of medication
interactions
 Knowledge, Deficient related to drug
 Assess lab values; APTT, PT, Hgb, Hct,
therapy, action, and side effects
platelet count
 Asses vital signs and neuro status
 Assess for menses in women, recent
surgery or trauma, bleeding disorders, or
history of hemorrhagic stroke or GI
bleeding
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of risks and benefits of drug therapy
 Remain free of unusual and excessive bleeding
 Maintain effective tissue perfusion
Implementation
Interventions and (Rationales)
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Monitor vital signs, especially blood
pressure and pulse. (Decreasing blood
pressure, increase in pulse may indicate
internal bleeding.)
Protect patient from injury by maintaining
limited mobility during drug therapy.
Monitor all possible sites of bleeding
during infusion
Monitor neurological status for
improvement if it is given for thrombotic
stroke. (If status deteriorates it could
indicate intracranial bleeding.)
Ensure that cardiac rhythm is monitored
during therapy. (Dysthrythmias may occur
with reperfusion of myocardium.)
Start IV lines and Foley catheter prior to
beginning therapy. (This will decrease
chance of bleeding from those sites.)
Monitor CBC during and after therapy for
indications of blood loss due to internal
bleeding. (Patient has increased risk of
Patient Education/Discharge Planning
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Advise patient regarding need for frequent
vital signs.
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Inform patient that activity will be limited
during infusion and pressure dressing may
be needed to prevent any active bleeding.
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Inform patient about assessments and why
they are necessary.
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Explain to patient that cardiac rhythm will
be monitored during treatment.
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Inform patient about procedures and why
they are necessary.
Instruct patient to:
 Restrict activity restriction because of
the possibility of increased bleeding
bleeding for 2-4 days post therapy.)
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Use a soft toothbrush and an electric
razor.
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 Metoprolol tartrate (Lopressor)
Potential Nursing Diagnoses
Assessment
 Tissue perfusion, Risk for Ineffective
Prior to administration:
related to adverse effects of medication
 assess standing and lying blood pressure,
 Injury, Risk for (dizziness/vertigo)
EKG, apical pulse, blood glucose, CBC,
related to adverse effects of medication
liver and kidney function
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Knowledge deficient related to
 Obtain complete health history including
medication therapy
allergies, drug history and possible drug
interactions.
 Assess for presence/history of
hypertension, angina, and cardiac
dysrhythmias.
 Obtain vital signs
 Obtain EKG, observe for presence of
sinus bradycardia, AV heart block, and
heart failure
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate understanding of the risks and benefits of medication therapy
 Maintain adequate tissue perfusion
 Avoid physical injury during drug therapy
Implementation
Interventions and (Rationales)
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Obtain apical pulse and blood pressure
prior to each dose. Withhold medication
if pulse is less than 60 bpm and systolic
blood pressure is less than 100.
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Encourage compliance with treatment
regimen. (Ventricular dyrhythmias or
thyroid storm may result if medication is
abruptly discontinued.)
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Observe for mood changes. (Depression
may result from this medication.)
Patient Education/Discharge Planning
Instruct patient regarding:
 Self monitoring of blood pressure and
pulse.
 Keeping a record of blood pressure and
pulse.
 Taking their blood pressure and pulse
prior to taking medication and to
withhold medication if pulse is less than
60 bpm or systolic blood pressure is less
than 100
Instruct patient to:
 Take medication as directed by the health
care provider/
 Avoid abrupt discontinuation of
medication.
 Instruct patient to notify health care
provider at the first signs and symptoms
of depression (difficulty sleeping, weight
loss, apathy, sadness).
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Monitor intake and output, and observe
for signs of heart failure.
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Monitor patients with asthma for
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respiratory distress. (Use cautiously with
patients with asthma because
bronchospasm may occur.)
Advise diabetic patients:
Monitor patients with diabetes mellitus
for signs of hypoglycemia. (Patients with
 To monitor blood sugar frequently. Usual
diabetes mellitus may need to reduce
insulin dosage may need to be reduced.
insulin dosage. More frequent monitoring
 Advise patient that medication may mask
of blood sugar may be needed because
tachycardia that accompanies
medication may mask signs and
hypoglycemia.
symptoms of hypoglycemia.)
Evaluation of Outcome Criteria
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Advise patient of early signs and
symptoms of heart failure (shortness of
breath, swelling of extremities, night
cough) and to report immediately to a
health care provide.
Instruct patients to report immediately
any wheezing or difficulty breathing.
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning).