Download Potential Nursing Diagnoses

Nursing Process Focus:
Patients Receiving Phenobarbital (Luminal)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Sensory perception, Disturbed related
to effects of drug.
 Obtain complete health history, including
allergies, neurological, pulmonary, cardiac,
 Injury, Risk for, related to seizure
renal, biliary, and mental disorders
activity
including blood studies: CBC, BUN,
 Nutrition: less than body requirements,
creatinine, electrolytes, PT, PTT, liver
Imbalanced, related to vitamin
enzymes, etc.
deficiency
 Obtain patient’s drug history to determine
 Knowledge, Deficient related to newly
possible drug interactions and allergies
prescribed drug.
 Assess neurological status, including
 Sleep Pattern, Disturbed. related to
identification of recent seizure activity.
medication induced somnolence
Planning: Patient Goals and Expected Outcomes
Patient will
 Experience the absence of, or reduction in the number or severity of, seizures.
 Avoid physical injury related to seizure activity or medication induced somnolence
 Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
 Monitor vital signs, especially blood
pressure and depth and rate of respirations.
(Because phenobarbital produces sedation,
respiratory depression occurs.)
 Keep resuscitative equipment accessible
(Phenobarbital may produce laryngospasm)
 Perform neuro-checks regularly, including
level of consciousness (LOC), according to
unit protocol. Excessive somnolence may
occur. Observe for persistent seizures.
Patient Education/Discharge Planning
Instruct the patient to:
 monitor vital signs regularly, particularly
blood pressure and respirations.
 withhold medication for any difficulty in
breathing or respirations below 12 breaths
per minute.
Instruct the patient to:
 Report any significant change in
sensorium: lethargy, stupor, or auras,
visual changes and other effects that may
indicate an impending seizure.
 Report dizziness which may indicate
hypotension.
 Monitor response to and effectiveness of
drug therapy
 Ensure patient safety by monitoring
ambulation until response of the drug is
known. Elevate bed rails; place call bell
within patient's reach.
 Monitor for adverse reactions, especially
due to CNS depression: confusion,
agitation, nightmares, GI upset, lethargy,
anxiety, cognitive changes, etc. (Changes in
response to medication may indicate
toxicity and requires evaluation.) Report
immediately.
 Monitor for signs of vitamin deficiency.
(Phenobarbital increases metabolism of the
nutrients Vitamin D, Vitamin K, folate and
other B vitamins. Vitamin D deficiency
results in impaired bone synthesis, Vitamin
K deficiency results in impaired blood
coagulation, other deficiencies result in
impaired cellular reproduction and repair,
causing anemia.)
 Obtain consult with dietitian per health care
provider's order as needed.
 Monitor for signs of hepatic or renal
toxicity. (Phenobarbital is metabolized by
the liver and excreted by the kidneys.)
 Monitor laboratory blood tests and
urinalysis: CBC with differential,
electrolytes, BUN, PT, PTT, liver enzymes,
etc. (Impaired function results in increased
serum drug levels.)
Instruct the patient to:
 Be aware that drug will cause initial
drowsiness; this effect may diminish with
continued therapy
 Avoid potentially hazardous activities that
require mental alertness (driving,
operating equipment etc)
 Bear in mind that full therapeutic effect of
oral phenobarbital may take 2-3 weeks;
 Not discontinue abruptly, or reduce
dosage, as increased seizure activity and/
or withdrawal symptoms may occur
 Keep a seizure log or diary to chronicle
symptoms
Instruct the patient to:
 Call for assistance when getting out of bed
or attempting to walk.
 Remove any tripping hazards from the
home environment.
 Instruct patient to immediately report any
idiosyncratic or disabling effects.
Instruct the patient or caregiver:
 Regarding the role of vitamins and
nutrition in maintaining health. Instruct
the patient to immediately report signs of
vitamin deficiency. Vitamin K: easy
bleeding (nasal, oral,rectal, etc.), tarry
stools, bruising, pallor. Vitamin D: Joint
pain, bone deformities. Vitamin B6: skin
changes, dandruff (seborrhea), peripheral
neuropathy, fatigue.
 Regarding intake of a nutrient-rich diet.
Instruct the patient to:
 Observe for signs of toxicity: nausea,
vomiting, diarrhea, rash, jaundice,
abdominal pain, tenderness or distention,
or change in color of stool, flank pain,
hematuria.
 Adhere to a regular schedule of laboratory
testing for liver and kidney function as
ordered by the health care provider
Instruct patient and caregiver:
 Use with caution in children, the elderly
and those with pre-existing diseases, such
 That children respond differently because
as respiratory disorders. These patients
their nervous systems are not yet fully
require reduced dosages. Paradoxical
mature.
response to drug may occur, which may
 The elderly are more susceptible to the
cause psychomotor agitation
effects of phenobarbital due to increased
(hyperactivity).
serum drug levels related to reduced
efficiency of the liver and kidneys as a
result of aging.
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 Phenytoin (Dilantin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Knowledge deficient related to drug
regimen, action, and side effects
 Obtain complete medical history including
allergies, developmental, neurological ,
 Altered nutrition:Nutrition altered less
pulmonary, cardiac, hematological, renal,
than body requirements, Imbalanced
biliary, and mental disorders including
related to nutrient deficiency
blood studies: CBC, BUN, creatinine,
 Oral mucous membrane, Impaired
electrolytes, PT, PTT, liver enzymes, etc.
related to drug effects.
 Obtain patient’s drug history to determine
 Skin integrity, Risk for impaired related
possible drug interactions and allergies
to adverse drug reaction
 Assess neurological status, including
 Injury, Risk for, related to drug side
identification of recent seizure activity.
effects
 Assess growth and development
Planning: Patient Goals and Expected Outcomes
The patient will:
 Report absence of seizure activity.
 Demonstrate understanding of drug action by accurately describing drug side effects and
precautions.
 Demonstrate proper daily oral hygiene.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 During IV infusion, monitor all VS and
 Instruct the patient to immediately report:
EKG. May need to ensure that patient’s
any difficulty breathing, palpitations, chest
cardiac output and central venous pressure
pain, dizziness or impending syncope.
be monitored according to ICU or ED
protocols.
Instruct the patient:
 Monitor neurological status, especially
changes in level of consciousness and/or
 Report any significant change in sensorium,
mental status. (At high doses, phenytoin
such as slurred speech, confusion,
may produce respiratory depression and
hallucinations, or extreme lethargy.
delirium.
 Report any changes in seizure quality or
unexpected involuntary muscle movement,
 Phenytoin may have a paradoxical effect,
producing involuntary movements such as
such as twitching, tremor or nystagmus.
dyskinesia or chorea.)
 Avoid driving and other activities requiring
mental alertness and physical coordination
until effects of the medication are known.

Monitor for adverse immune reaction, such
as hypersensitivity syndrome and
dermatological manifestations such as
purpuric dermatitis or Stevens-Johnson
syndrome.
Instruct the patient to:
 Immediately report shortness of breath,
wheezing, tightness in the throat, itching or
any changes in the skin such as a measleslike ("morbilliform") rash or dermatitis
fever, joint pain, profound fatigue
 Call the health care provider immediately
(before the next scheduled dose) for any
adverse reaction
 Keep in mind that abrupt cessation of the
drug can cause rebound seizures.
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Instruct patient to:
 Keep a "seizure diary" during drug initiation
phase, or during dose adjustment.
 Take the medication exactly as ordered,
including the same manufacturer's drug
each time the prescription is refilled.
Switching brands may result in alterations
in seizure control.
 Take a missed dose as soon as remembered,
but do not double doses to "catch up"
(doubling doses could result in toxic serum
level)
Instruct patient to:
Use cautiously in the elderly. (Diminished
kidney and liver function related to aging
 Keep all appointments for follow-up lab
result in lowered drug clearance and
studies
increased serum drug levels.)
 Report signs of toxicity to the health care
provider immediately
Instruct
the patient to:
Monitor oral health. Observe for signs of
gingival hypertrophy, bleeding,
 Use a soft toothbrush, and oral rinses as
inflammation, etc.
prescribed by the dentist.
 Avoid mouthwashes containing alcohol,
which dries mucous membranes.
 Brush and floss teeth after every meal;
massage the gums daily.
 Report changes in oral health such as
excessive bleeding or inflammation of the
gums
 Maintain regular schedule of dental visits.
Provide patient with information concerning Instruct the patient:
contraceptive use. (Phenytoin may reduce
 Remain abstinent or use reliable birth
the effectiveness of oral contraceptives.)
control while taking this medication.
 Inform the health care provider if pregnancy
occurs
 Avoid abrupt cessation of the drug; rebound
seizures may cause harm to the fetus
 Phenytoin dose requirements increase
during pregnancy.
Instruct the patient to:
Monitor serum glucose and observe for
signs of diabetes mellitus. (Phenytoin alters  Observe for subtle signs of hyperglycemia
glycemic control and may cause
(e.g. polydipsia, polyuria, slow wound
hyperglycemia.)
healing, etc.)
 Regularly monitor blood and/or urine
glucose levels as specified by the health
care provider
 Adhere to a calorie-controlled low refined
Monitor effectiveness of drug therapy.
Observe for developmental changes
indicating the need for dose adjustment.
(Phenytoin needs increase with initial
maturing, especially at puberty, a time of
rapid growth.)
sugar (or ADA) diet as prescribed by the
health care provider.
Instruct
the patient to:
 Monitor laboratory tests such as CBC,
BUN, creatinine, electrolytes including
 Report shortness of breath, profound
serum calcium, urinalysis and liver enzymes
fatigue, pallor (signs of anemia)
to determine kidney and liver function.
 Report nausea, vomiting, diarrhea, rash,
(Phenytoin is metabolized in the liver and
jaundice, abdominal pain, tenderness,
excreted by the kidneys; impaired organ
distention, or change in color of stool.
function can increase serum drug levels.)
 Adhere to laboratory testing regimen for
blood tests and urinalysis as directed.
 Include effects of phenytoin use on lab tests Inform the patient that:
in teaching plan.
 Phenytoin may cause false positive resultsw
*Reduces free thyroxine levels
on tests for hypothyroidism, ant other
*Reduces 17 keto-steroid levels
endocrine tests.
*Decreases dexamethasone suppression
 Should inform patient to notify laboratory
values, and urine 6-b hydroxycortisol levels.
personnel of phenytoin drug therapy when
providing blood or urine samples.
Instruct
the patient to:
 Monitor nutritional status. (Phenytoin's
action on electrolytes at the cellular level
 Eat well balanced meals high in vitamins
[desensitizing sodium channels] contributes
and nutrients.
to decreased absorption of folic acid,
 Regularly take vitamin and mineral
vitamin D, magnesium and calcium. Folic
supplements (Vitamin D, folic acid,
acid deficiency leads to anemia; vitamin D,
magnesium, and calcium) as recommended
magnesium and calcium deficiencies lead to
by the health care provider.
osteoporosis.)
Instruct patient to:
 Observe patterns of elimination.
(Phenytoin's central nervous system
 Take the drug with food to reduce
depressant effects decrease gastrointestinal
gastrointestinal upset.
motility, producing constipation.)
 Immediately report any severe or persistent
heartburn, upper G.I. pain, nausea or
vomiting.
 Increase exercise, fluid and fiber intake to
facilitate stool passage
 Consult the health care provider regarding
the need for a bulk laxative or stool softener
for chronic constipation.
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 Ethosuximide (Zarontin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Knowledge deficient related to drug
therapy, side effects and precautions.
 Obtain complete medical history:
neurological, hematological, pulmonary,
 Thought processes, Disturbed related to
cardiac, renal, biliary, and mental disorders
side effects of drug.
including blood studies: CBC, BUN,
 Nutrition: less than body requirements,
creatinine, electrolytes,PT, PTT, liver
Imbalanced, related to weight loss
enzymes, etc.
 Oral mucous membrane, Impaired, related
 Obtain patient’s drug history to determine
to drug side effects.
possible drug interactions and allergies
 Injury, Risk for related to drug side
 Assess neurological status, including
effects.
identification of recent seizure activity.
 Assess mental status, including affect and
lucidity.
 Assess gastrointestinal status, including
identification of biliary tract or upper
digestive discomfort
 Assess growth and development.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Experience the absence of, or a reduction in, the number or severity of seizures.
 Avoid physical injury related to seizure activity or medication induced sensory changes.
 Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions
 Maintain intact mucous membranes
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient:
 Monitor vital signs especially temperature
and respiratory patterns, especially
 Regarding methods to monitor vital signs at
during sleep.
home, especially temperature and
respirations, ensuring proper use of home
equipment. Elevated temperature may result
from infection or indicate a blood disorder.
 That snoring is NOT normal; it is a sound
created by obstruction in the upper
respiratory tract which may signal sleep
apnea and should be reported.
 Monitor neurological status, especially
changes in level of consciousness and/or
mental status.
 Observe for psychosis and/or labile
emotions, especially mental depression.
 Obtain a verbal "no-self-harm" contract
from patients with significant mental
depression.
Instruct the patient to:
 Report any significant change in sensorium
such as visual changes (myopia), confusion,
difficulty concentrating, hallucinations, or
psychomotor agitation.
 Report dizziness, headache, lethargy,
fatigue, ataxia, sleep pattern disturbances or
hiccups.
 Report any changes in seizure quality or
unexpected involuntary muscle movement.
 Avoid driving and other activities requiring
mental alertness and physical coordination
until effects of the medication are known.
 Instruct patient to report any severe
dysphoria, especially suicidal ideation.
 Monitor for adverse hypersensitivity
reaction, including dermatological
manifestations / Stevens-Johnson
syndrome.
Instruct the patient to:
 Immediately report shortness of breath,
wheezing, tightness in the throat, itching or
any changes in the skin such as rash or
dermatitis
 Call the health care provider immediately
(before the next scheduled dose) for any
adverse reaction
 Keep in mind that abrupt cessation of the
drug can cause rebound seizures.
Monitor immune status.
 Observe for signs of infection which may
indicate insidious onset of blood dyscrasia:
fever, sore throat, malaise, joint pain,
ecchymoses, profound fatigue, shortness of
breath, pallor, etc. Report immediately.
Instruct the patient or caregiver
 Immediately report any "flu-like" symptoms:
shortness of breath, fever, sore throat,
malaise, joint pain, profound fatigue, etc.
 Flu-like symptoms may herald the "silent"
onset of serious blood disorder, such as bone
marrow suppression.
 Bruising is a sign of bleeding which can also
indicate the presence of a serious blood
disorder.
 Monitor laboratory tests such as CBC,
BUN, creatinine, electrolytes, (including
serum calcium), PT, PTT, liver enzymes
and urinalysis, to determine kidney and
liver function. (Ethosuximide is
metabolized in the liver and excreted by the
kidneys; impaired organ function may
result.)
Instruct the patient to:
 Immediately report any distressing
symptoms to the health care provider.
 Adhere to laboratory testing regimen for
blood tests and urinalysis as directed by the
health care provider.
Monitor renal function.
 Monitor intake & output
 Observe for signs of nephrotoxicity,
including oliguria and pitting edema.
 Monitor laboratory values (see previous
box above).
Instruct the patient to:
 Monitor fluid intake and output.
 Immediately report changes in urine color,
character or output (hematuria, oliguria,
cloudiness, etc.)
 Immediately report nausea, fever, malaise
and/or flank pain.
Monitor gastrointestinal status.
 Observe for signs of gastrointestinal
bleeding or hepatic toxicity. Monitor
gastrointestinal elimination; conduct guiac
stool testing for occult blood.
Monitor nutritional status.
 Observe for weight loss secondary to
anorexia.
Monitor effectiveness of drug therapy.
 Observe for developmental changes
indicating the need for dose adjustment.
 (Ethosuximide needs increase with initial
maturing, especially at puberty, a time of
rapid growth.)
 Use cautiously in the elderly. (Diminished
kidney and liver function related to aging
result in lowered drug clearance and
increased serum drug levels.)
 Inform patient of need to use alternate
forms of birth control. (Drug may
decrease effectiveness of oral
contraceptives.)
Instruct the patient:
 Report any frank bleeding, abdominal pain,
anorexia, heartburn, nausea, vomiting,
jaundice or a change in the color or character
of stools. Vomiting brown emesis that looks
like coffee grounds or passing tarry stools
are signs of gastrointestinal bleeding.
 Regarding the method of obtaining stool
samples and home testing for occult blood as
indicated by the health care provider.
 Adhere to a regimen of laboratory testing as
ordered by the health care provider and keep
all follow-up appoints as scheduled.
Instruct patient:
 Measure body weight weekly
 Inform the health care provider of losses,
especially greater than two pounds
 Regarding measures to enhance weight
maintenance and appetite: small frequent
meals, calorie-dense snacks, nutritional
supplement drinks, etc.
 Consult with a nutritionist or dietician as
ordered by the health care provider.
Instruct the patient
 Take the medication exactly as ordered,
including the same manufacturer's drug each
time the prescription is refilled. Switching
brands may result in alterations in seizure
control.
 Take a missed dose as soon as remembered,
but do not double doses to "catch up"
(doubling doses could result in toxic serum
level)
 Instruct the patient to report symptoms of
drug toxicity such as visual changes,
hallucinations, headache, or dizziness.
Instruct the patient:
 Remain abstinent or use reliable birth
control while taking this medication.
 Inform the health care provider if pregnancy
occurs
 Avoid abrupt cessation of the drug; rebound
seizures may result.
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 Diazepam (Valium)
NOTE: this information is specific to the use of diazepam as a treatment for epilepsy only, not
to other uses, such as anxiety.
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Airway Clearance, Ineffective related to
sedative effect of drug
 Obtain patient’s drug history to determine
possible drug interactions and allergies,
 Injury, Risk for related to sedative effect of
including history of anti-seizure drug
drug
therapy and alcohol or tobacco use.
 Confusion, Acute related to drug side effects
 Assess neurological status, including
 Skin integrity, Risk for impaired related to
LOC. Identify type and etiology of recent
adverse drug reaction
seizure activity.
 Sensory perception, Disturbed related to drug
 Assess growth and development,
side effect
including age, body mass index, and
 Knowledge Deficient , related to drug action,
pregnancy/lactation status.
side effects
 Assess skin integrity and identify
locations for venipuncture/intravenous
drug administration; insert intravenous
catheter and I.V. line if not present.
 Obtain complete medical history:
neurological ,pulmonary, cardiac,
hematologic, renal, biliary, and mental
disorders and including laboratory values:
serum anticonvulsant level, CBC, BUN,
creatinine, electrolytes, PT, PTT, and
liver enzymes.
Note: *Diazepam is given in response to
status epilepticus, a medical emergency.
Obtain as much key data as possible.
Planning: Patient Goals and Expected Outcomes
Patient will:

Maintain a patent airway and adequate tissue perfusion.

Experience the cessation of tonic-clonic seizures of status epilepticus.

Avoid serious physical injury related to status epilepticus.

Experience the return of normal consciousness and achieve stable neurological status.

Demonstrate an understanding of the drug's action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Monitor respiratory rate and breathing
 Instruct patient and caregivers that keeping an
pattern, as well as pulse oximetry and/or
open airway and having sufficient oxygen is
arterial blood gases.
necessary to prevent permanent brain damage,
which may occur related to status epilepticus.
 Assist with placement of an oral airway,
or intubation as needed. Provide suction
between seizures. Administer oxygen as
ordered. Keep resuscitative equipment
accessible.
Instruct patient/caregivers that:
 During IV infusion, monitor all vital
signs and EKG. May need to ensure that
 Status epilepticus is a life threatening emergency
cardiac output and central venous
and that direct IV administration of diazepam also
pressure per Intensive Care Unit or
has risks such as respiratory and cardiac
Emergency Department protocol.
depression or arrest.
 Observe for severe respiratory depression  All necessary measures are being taken to preserve
and bradycardia. (Diazepam is a CNS
life and neurologic function.
depressant which affects
cardiorespiratory status.)
 Monitor neurological status. Observe for Instruct patient/caregiver to:
changes in level of conscious. (Status
 Always take anti-seizure medication exactly as
epilepticus generally causes loss of
prescribed.
consciousness; patients are at risk of
 Inform the health care provider of any other
entering a coma due to increased cerebral
illness; don't self-medicate with OTC medications.
metabolic demand.)
 Avoid using alcohol, tobacco and recreational
 Observe for rebound seizures. (Diazepam
drugs.
is very short-acting.)
 Monitor metabolic status. (Increased
 Advise caregivers regarding variations in fluid and
temperature increases metabolic
electrolytes which may increase susceptibility to
demands; lactic acidosis may follow
seizures
generalized motor seizures as common in
status epilepticus.)
 Monitor fluid and electrolyte balance and
intake and output. (Electrolyte
imbalances may precipitate status
epilepticus.)
Instruct patients and caregivers to:
 Ensure patient safety. Place patient in
semi-prone position, with head turned to
 Review standard safety precautions regarding
reduce the risk of aspiration. Pad
seizure activity
siderails. Remove any restrictive
 Follow guidelines for seizures requiring
clothing. Anchor IV lines per unit
emergency intervention and transport to a
protocol.
hospital.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes
have been met (see “Planning”).