Download Nursing Process Focus: Lorazepam (Ativan)

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”)