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Nursing Process Focus: Patients Receiving Lorazepam (Ativan) Assessment Potential Nursing Diagnoses Prior to administration: Injury, Risk for, related to sedative effect of drug Obtain complete medical history: 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 Instruct patient: Ensure patient safety. Raise bedrails; place to request assistance when getting out of bed and ambulating until effect of drug is call bell within patient's reach. known Lorazepam causes drowsiness and dizziness. to avoid activities that require mental alertness and good physical coordination until effect of drug is known Instruct patient: Monitor patient for signs of digoxin 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.) Instruct patient Monitor vital signs especially pulse, 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 for, related to Prior to administration: sedative effect of drug Obtain complete medical Sleep pattern, Disturbed, related to effects of history, including, drug allergies, data on sleep Memory, Impaired, related to side effect of drug habits, mental status and Knowledge, Deficient, related to new drug any family history of regimen sleep disorders, and laboratory findings such as CBC, BUN creatinine, and liver enzymes. Obtain patient’s drug history to 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 Patient Education / Discharge Planning (Rationales) Monitor patients having a Advise patient primary sleep disorder, To report symptoms of night time shortness of especially central sleep breath, snoring, or headache upon awakening to the apnea. (The CNS health care provider before taking this medication. depressant effect can That snoring is NOT normal, and is the sign of further reduce the altered obstruction in the upper respiratory tract. respiratory drive responsible for apnea.) Monitor vital signs especially respiration, pulse and blood pressure. (The drug's CNS effects can slow or diminish breathing.) Provide for patient safety by toileting patient prior to medicating, putting Instruct patient or caregiver to monitor breathing patterns, and to observe for snoring or apnea. Instruct the patient To request assistance when getting out of bed To remove items from the home that pose a tripping side rails up, placing call bell nearby, etc. (Grogginess can cause the patient to become disoriented, and to forget or disregard object placement.) Monitor mental status and level of consciousness. (The drug's affect on the hippocampus and cerebral cortex may cause confusion or amnesia.) Monitor mental health status and evaluate risk potential for suicide. Monitor the environment for signs of hoarding medication. Obtain a noself 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 hazard. Instruct the patient or caregiver to report significant changes in mental status, such as extreme lethargy or disorientation, especially occuring in the daytime. 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 nonpharmacologic 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. the liver and excreted by Instruct the patient to keep all follow-up appoints as the kidneys; directed by the health-care provider. impaired organ function can increase serum drug levels.) Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”)