Download Nursing Process Focus: Patients Receiving Lorazepam (Ativan

Nursing Process Focus:
Patients Receiving Lorazepam (Ativan)
Assessment
Potential Nursing Diagnoses
Prior to administration:
• Injury, Risk for, related to sedative
• Obtain complete medical history:
effect of drug
pulmonary, cardiac, renal, biliary, and
• Memory, Impaired related to side effect
mental or sleep disorders, including EKG
of drug
and laboratory studies: CBC, BUN,
• Knowledge, Deficient, related to newly
creatinine, electrolytes, liver functions
prescribed drug
tests.
• Ineffective individual coping
• Obtain patient’s drug history to determine
• Sleep pattern Disturbed, related to side
possible drug interactions and allergies
effect of drug
Planning: Patient Goals and Expected Outcomes
Patient will:
• Experience an increase in psychological comfort
• Report absence of physical and behavioral manifestations of anxiety
• Demonstrate understanding of the drug's action by accurately describing drug side effects
and precautions.
• Remain free of injury
• Maintain intact memory
Implementation
Interventions and (Rationales)
Patient Education / Discharge Planning
• Ensure patient safety. Raise bedrails;
Instruct patient:
place
• to request assistance when getting out of
• call bell within patient's reach.
bed and ambulating until effect of drug is
Lorazepam causes drowsiness and
known
dizziness.
•
to avoid activities that require mental
alertness and good physical coordination
until effect of drug is known
• Monitor patient for signs of digoxin
Instruct patient:
toxicity. (Lorazepam may contribute to • also taking digoxin of the symptoms of
digoxin toxicity by increasing the
digoxin intoxication.
serum digoxin level. Symptoms include • to immediately report signs and symptoms
visual changes such as yellow auras,
of digoxin toxicity.
blurring or diplopia; nausea, vomiting
and diarrhea, paraesthesias, dizziness,
confusion, vertigo, profound weakness,
syncope, etc.)
• Monitor vital signs especially pulse,
Instruct patient
respirations, and blood pressure.
• Regarding methods to monitor vital signs
Observe respiratory patterns, especially
at home, especially respirations, as needed,
during sleep, for evidence of apnea or
and that snoring is NOT normal; it is a
shallow breathing. (Lorazepam can
sound created by obstruction in the upper
reduce the respiratory drive in
respiratory tract.
susceptible patients.)
•
•
Monitor the patient's intake of ordinary
stimulants, including caffeine (in
beverages such as coffee, tea, cola and
other soft drinks and over-the-counter
analgesicssuch as Excedrin®), and
nicotine (smoking, tobacco-chewing
and nicotine patches).
Monitor vital signs and neurological
status, especially level of consciousness
(LOC).
•
Monitor affect and emotional status.
Monitor for depression, especially with
suicidal tendencies: use with caution.
(Drug may increase risk.)
•
Monitor liver function. (Lorazepam is
metabolized in the liver, creating the
risk for liver toxicity.) Signs and
symptoms include nausea, vomiting,
diarrhea, rash, jaundice, abdominal
pain, tenderness or distention, or
change in color of stool.
Use with caution in patients who have
or are suspected as having a primary
sleep disorder. (The CNS depressant
effect of lorazepam can further affect
the altered respiratory drive responsible
for central sleep apnea and can increase
muscle relaxation in the upper airway,
enhancing mechanical occlusion of the
upper airway, and worsening
obstructive sleep apnea. CNS
depressants exacerbate
hypersomnolence (excessive daytime
sleepiness) associated with narcolepsy)
Avoid abrupt discontinuation of
therapy. (Withdrawal symptoms are
possible with abrupt discontinuation
after long term use.)
•
•
•
Instruct the patient that caffeine and
nicotine (and other stimulants) can reduce
the drug's effectiveness.
Instruct patient to report significant
changes in neurological status, such as
extreme lethargy, slurred speech,
disorientation or ataxia.
Instruct patient:
• To report significant mood changes,
especially depression.
• Obtain a verbal "no-self harm" contract
from the patient.
• To keep all follow-up appoints as directed
by health-care provider.
Instruct the patient:
• To report signs and symptoms of hepatic
toxicity.
• To adhere to a regular schedule of
laboratory testing for liver function as
ordered by the health care provider.
•
•
Advise patient that, if snoring occurs,
consult the health care provider before
taking this medication.
Instruct patient
• To take drug exactly as prescribed.
• To keep follow up appointments to monitor
response to medication.
• That abrupt discontinuation may result in
rebound anxiety and sleeplessness, possibly
of enhanced intensity.
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 Zolpidem (Ambien)
Assessment
• Potential Nursing DiagnoseRisk
Prior to administration:
for, related to sedative effect of
• Obtain complete medical history,
drug
including, allergies, data on sleep
• Sleep pattern, Disturbed, related to
habits, mental status and any family
effects of drug
history of sleep disorders, and
• Memory, Impaired, related to side
laboratory findings such as CBC, BUN
effect of drug
creatinine, and liver enzymes.
• Knowledge, Deficient, related to
• Obtain patient’s drug history to
new drug regimen
determine possible drug interactions
and allergies
Planning: Patient Goals and Expected Outcomes
Patient will:
• Experience comfortable, timely onset of night-time sleep and
restoration of normal sleep/wake pattern.
• Demonstrate understanding of sleep hygiene and factors that facilitate sleep.
• Demonstrate understanding of the drug's action by accurately describing drug side
effects and precautions.
• Remain free of injury during course of drug therapy.
Implementation
Interventions and (Rationales)
Patient Education / Discharge Planning
• Monitor patients having a primary
Advise patient
sleep disorder, especially central sleep • To report symptoms of night time
apnea. (The CNS depressant effect can
shortness of breath, snoring, or
further reduce the altered respiratory
headache upon awakening to the health
drive responsible for apnea.)
care provider before taking this
medication.
• That snoring is NOT normal, and is the
sign of obstruction in the upper
respiratory tract.
• Monitor vital signs especially
• Instruct patient or caregiver to monitor
respiration, pulse and blood pressure.
breathing patterns, and to observe for
(The drug's CNS effects can slow or
snoring or apnea.
diminish breathing.)
• Provide for patient safety by toileting
Instruct the patient
patient prior to medicating, putting side • To request assistance when getting out
rails up, placing call bell nearby, etc.
of bed
(Grogginess can cause the patient to
• To remove items from the home that
become disoriented, and to forget or
pose a tripping hazard.
disregard object placement.)
• Monitor mental status and level of
• Instruct the patient or caregiver to
consciousness. (The drug's affect on
report significant changes in mental
the hippocampus and cerebral cortex
status, such as extreme lethargy or
may cause confusion or amnesia.)
disorientation, especially occuring in
the daytime.
•
Monitor mental health status and
evaluate risk potential for suicide.
•
Monitor the environment for signs of
hoarding medication. Obtain a no-self
harm verbal contract from patients
identified as being at risk of suicide.
•
Document patient’s sleep patterns and
response to medication
•
Monitor gastrointestinal elimination.
Observe for nausea, vomiting, and
dyspepsia. CNS depressants may
reduce gastrointestinal motility.
(Gastrointestinal distress may also
signal hepatotoxicity. )
Monitor laboratory tests such as CBC,
BUN, creatinine, urinalysis and liver
enzymes to determine kidney and liver
function. (Zolpidem is metabolized in
the liver and excreted by the kidneys;
impaired organ function can increase
serum drug levels.)
• Advise patient to report signs of
depression to the health care provider
immediately.
Instruct patient or caregivers:
• To take medication as prescribed.
• To assure medications are swallowed.
• Instruct patients at risk for mental
depression to demonstrate swallowing
of the medication.
Advise patient:
• Of short term use of medications and
encourage non-pharmacologic
strategies to improve sleep
• That long-term insomnia may signal
another underlying medical disorder
and should be investigated by the
health care provider.
• Inform patient that food decreases
absorption and will delay onset of
effects.
Advise patient
• To inform the health care provider of
any history of liver or kidney problems.
• To report nausea, vomiting, diarrhea,
rash, jaundice, abdominal pain,
tenderness, distention, or change in
color of stool.
• To adhere to laboratory testing regimen
for serum blood level tests of liver
enzymes as directed. Instruct the patient
to keep all follow-up appoints as
directed by the health-care provider.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”)
•