Prepare for your exams
Get points
Guidelines and tips

Prepare for your exams

Study with the several resources on Docsity

Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips

Sell on Docsity

Log in Sign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search Store documents

The best documents sold by students who completed their studies

Search through all study resources

Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents

20 Points

For each uploaded document

Answer questions

5 Points

For each given answer (max 1 per day)

All the ways to get free points

Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

University Rankings

Discover the best universities in your country according to Docsity users

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

From our blog

Exams and Study

Go to the blog

Nursing Diagnoses & Interventions for Medication Therapy: Patient Goals & Outcomes, Study notes of Nursing

New York Technical Institute of Hawaii Nursing

Potential nursing diagnoses, patient goals, and expected outcomes for medication therapy. It includes interventions and rationales for various diagnoses related to medication side effects, nutritional imbalances, and disturbed body image. The document emphasizes the importance of patient education and monitoring vital signs.

What you will learn

What are the potential nursing diagnoses related to medication side effects?
What are the patient goals and expected outcomes for medication therapy?
What are the common side effects of high doses of medications and how can they be monitored?

What interventions are recommended for patients at risk for infection related to medication?
What precautions should be taken before administering medication to patients with renal insufficiency?

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

lakshminath 🇺🇸

4

(2)

223 documents

1 / 20

This page cannot be seen from the preview

Don't miss anything!

Nursing Process Focus:

Patients Receiving Hepatitis B Vaccine (Recombinant)

Assessment

Prior to administration:

• Assess for possible exposure to HBV.

Possible signs/symptoms include: flu-

like symptoms, GI symptoms, joint or

RUQ pain, jaundice, clay-colored stool,

and/or dark urine. Those exposed to the

virus will need a combination therapy of

both the hepatitis B vaccine and the

Hepatitis B Immune Globulin

• Obtain blood work for those with

possible exposure: HBsAG viral

antigen/antibodies, complete blood

count, electrolytes, liver enzymes (ALT,

ALP, AST, GGT, & LDH), bilirubin

levels, and prothrombin time.

• Assess patient’s drug history/allergy to

determine possible sensitivity to baker’s

yeast or previous dose of hepatitis B

vaccine.

Potential Nursing Diagnoses

• Injury, Risk for related to side effects of

medication

• Knowledge, Deficient related to

administration of medication

Planning: Patient Goals and Expected Outcomes

The patient will:

• Complete the series of vaccinations according to recommended immunization schedule

• Remain free of signs and symptoms of Hepatitis B

Implementation

Interventions and (Rationales) Patient Education/Discharge Planning

Identify “at risk populations” for Hepatitis.

These include

People who have more than one sex

partner in 6 months

Men who have sex with other men

Sex contacts of infected persons

People who inject illegal drugs

Health care and public safety workers

Household contacts of persons with

chronic HBV

Hemodialysis patients

• Educate at “risk populations” concerning

the availability of immunizations

throughout the community; i.e., local health

departments and clinics.

• Monitor for flu-like symptoms. Those who

are ill should wait until they recover before

getting the vaccine.

• Instruct patient to report any flu-like

symptoms, GI upset, changes in urine or

stool color before getting vaccine

Partial preview of the text

Download Nursing Diagnoses & Interventions for Medication Therapy: Patient Goals & Outcomes and more Study notes Nursing in PDF only on Docsity!

Nursing Process Focus: Patients Receiving Hepatitis B Vaccine (Recombinant)

Assessment Prior to administration:

Assess for possible exposure to HBV. Possible signs/symptoms include: flu- like symptoms, GI symptoms, joint or RUQ pain, jaundice, clay-colored stool, and/or dark urine. Those exposed to the virus will need a combination therapy of both the hepatitis B vaccine and the Hepatitis B Immune Globulin
Obtain blood work for those with possible exposure: HBsAG viral antigen/antibodies, complete blood count, electrolytes, liver enzymes (ALT, ALP, AST, GGT, & LDH), bilirubin levels, and prothrombin time.
Assess patient’s drug history/allergy to determine possible sensitivity to baker’s yeast or previous dose of hepatitis B vaccine.

Potential Nursing Diagnoses

Injury, Risk for related to side effects of medication
Knowledge, Deficient related to administration of medication

Planning: Patient Goals and Expected Outcomes The patient will:

Complete the series of vaccinations according to recommended immunization schedule
Remain free of signs and symptoms of Hepatitis B

Implementation

Interventions and (Rationales) Patient Education/Discharge Planning

Identify “at risk populations” for Hepatitis. These include People who have more than one sex partner in 6 months Men who have sex with other men Sex contacts of infected persons People who inject illegal drugs Health care and public safety workers Household contacts of persons with chronic HBV Hemodialysis patients

Educate at “risk populations” concerning the availability of immunizations throughout the community; i.e., local health departments and clinics.
Monitor for flu-like symptoms. Those who are ill should wait until they recover before getting the vaccine.
Instruct patient to report any flu-like symptoms, GI upset, changes in urine or stool color before getting vaccine

Ensure infants receive the vaccine according to recommended schedule

Instruct infant caregivers of immunization schedule:

within 12 hours of birth
2 nd^ dose: 1-2 months of age
3 rd^ dose: 6 months of age. The third dose should not be given before 6 months of age because this could reduce long- term protection.
Ensure older children, adolescents or adults receive the vaccine according to recommended immunization schedule.

Instruct patient of immunization schedule:

1 st^ dose: anytime
2 nd^ dose: 1-2 months after first dose
3 rd^ dose: 4-6 months after first dose If dose is missed, next dose should be received as soon as possible.
Monitor for common side effects such as soreness at injection site and fever
Instruct patient to notify health care provider if fever occurs or soreness at injection site lasts longer than a couple of days.
Monitor for possible allergic reactions such as difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, tachycardia or dizziness.
Instruct patient to notify health care provider of any signs or symptoms of an allergic reaction

Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”).

Monitor for common side effects such as muscle aches, fever, weight loss, loss of appetite, nausea and vomiting and arthralgia due to high doses of medications. Report to health care provider.

Instruct patient to:

Take medication at bedtime to reduce side effects
Use frequent mouth care and small frequent feedings to reduce gastrointestinal disturbances
Monitor blood glucose levels. (Blood sugar may increase in patients with pancreatitis.)
Instruct patient to have blood glucose checked at regular intervals.
Monitor for changes in mental status. (May cause depression, confusion, fatigue, visual disturbances, and numbness. Alpha-interferons cause or aggravate neuropsychiatric disorders. Mechanism of action undetermined.)
Instruct patient to notify health care provider of any mental changes.

Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Cyclosporine (Neoral, Sandimmune)

Assessment Prior to administration

Assess for presence/history of organ transplant, grafting, active infection, and pregnancy
Assess for skin integrity, specifically look for lesions and skin color
Obtain blood work: complete blood count, electrolytes, and liver function
Obtain vital signs especially temperature and blood pressure
Assess patient’s drug history/allergy to determine possible sensitivity to polyoxyethylated castor oil

Potential Nursing Diagnoses

Infection, Risk for related to depressed immune response secondary to medication
Injury, Risk for related to thrombocytopenia secondary to side effects of medication
Knowledge, Deficient, related to drug action and side effects

Planning: Patient Goals and Expected Outcomes

The patient will:

Remain free of elevated temperature, unusual bleeding, sore throat, mouth ulcers, fatigue
Demonstrate complianewith all laboratory tests needed to monitor this medication
Demonstrate understanding of signs and symptoms of side effects related to medication Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor renal function. (May cause nephrotoxicity. 75% of patients experience decreased urine flow due to changes physicological in the kidneys such as microcalcification and interstitial fibrosis.)

Advise patient to:

Keep good record of urine output
Report significant reduction in urine follow to the health care provider
Monitor liver function (due to an increased risk for liver toxicity).
Instruct the patient concerning the importance of regular blood work.
Watch for signs and symptoms of infection. (There is an increased risk of infection.)

Instruct patient:

Regarding importance of good, frequent handwashing.
To avoid crowds and anyone who has infection
Monitor vital signs especially temperature and blood pressure. (As a side effect of this medication especially related to those with kidney transplants, hypertension may occur in 10-15% of patients. Increased temperature may indicate infection.)
Teach patients to monitor blood pressure and temperature ensuring proper use of home equipment and compliance with doctor’s appointments.

Nursing Process Focus: Patients Receiving Prednisone (Meticorten)

Assessment Prior to administration:

Obtain complete drug history including allergies, drug history and possible drug interactions
Assess vital signs
Assess for history of organ transplant, acute inflammation, diabetes mellitus
Obtain serum electrolytes

Potential Nursing Diagnoses

Nutrition: more than body requirements, Risk for Imbalanced: related to weight gain from medication
Fluid volume, Excess related to fluid retention secondary to medication
Body image, Disturbed related to physical changes secondary to medication
Injury, Risk for (infection) related to immunosuppression from medication
Skin Integrity, Risk for Impaired related to tissue fragility secondary to medication Planning: Patient Goals and Expected Outcomes The patient will:
Maintain body weight within normal range
Remain free of edema in lower extremities
Demonstrate positive body image
Maintain intact skin integrity Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor vital signs, especially blood pressure (to determine need for possible treatment of fluid and electrolyte disorders and renal insufficiency).
Use cautiously in patients with renal insufficiency (due to the drug’s ability to retain water and sodium and the main excretion of drug is by the renal system).
Inform patient to report to health care provider any signs and symptoms of fluid retention; e.g. increase in weight by 2 lbs in a 1 week, swelling of hands and feet, difficulty breathing.
Monitor complete blood count. (Capillaries become more permeable resulting in vasoconstriction. Red blood cells increase, causing decrease in white blood cells.)
Inform patient concerning the need to for periodic lab testing
Obtain medical history of myasthenia gravis (due to the possible adverse effect of exacerbation of respiratory failure).
Instruct patient to report any difficulty in breathing to health care provider immediately.
Monitor blood sugar. (Use cautiously in patients with diabetes mellitus due to drug’s effect on blood sugar, causing hyperglycemia. Patients may require increased doses of a glucose-lowering drug.)

Instruct patient:

May increase insulin needs while on this medication
To increase blood sugar monitoring and to report increased blood sugar to health care provider.

Monitor for signs and symptoms of infection or inflammation. (Medication may mask usual signs of infection. Use cautiously in patients with acute active infections. Contraindicated in patients with systemic fungal infection due to the possibility of interaction with the acute infection and the risk for superinfections.)

Instruct patient to:

Avoid all contact with individuals with infections
Wash hands frequently and to clean all counters completely after food preparation
Monitor compliance with medication regimen.

Instruct patient:

Take medication exactly as scheduled and to never abruptly stop medication.
Avoid taking any OTC drugs without checking with the health care provider.
Monitor intake and output (due to drug’s ability to cause water and sodium retention).

Instruct patient to:

Weigh self regularly
Report any sudden weight gain to the health care provider
Obtain history of gastrointestinal disorders.
(Use cautiously in patients with active peptic ulcer disease due to inhibiting production of cytoprotective mucous and reduction of GI mucosal blood flow that can lead to gastric ulceration.)

Advise patient to take medication with food to decrease gastrointestinal distress.

Use extreme care during venipuncture due to capillary fragility. (Capillary fragility is due to the suppression of protein synthesis by the glucocorticoids’ effect.) - Advise patient to carry some form of identification stating the medication the patient is taking.
Evaluate risk for osteoporosis. (Use cautiously in patients with osteoporosis due to drug’s effect to cause suppression of bone formation by osteoblasts, hence to worsen symptoms of osteoporosis.) - Advise patient to consume nutritious low calorie foods and to increase dietary calcium to combat osteoporosis.

Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Monitor pain level (to determine effectiveness of drug therapy). - Instruct patient to report changes in pain level to health care provider.
Monitor blood sugar in patients with diabetes mellitus. (Acetaminophen may decrease insulin needs.) - Advise patient that this medication may cause hypoglycemia.

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 Diphendrydramine (Benadryl)

Assessment Prior to administration:

Obtain complete health history including allergies, drug history and possible drug interactions
Obtain presence/history of allergic or anaphylactic reactions
Obtain vital signs
Obtain history of glaucoma, diabetes mellitus, seizure disorder

Potential Nursing Diagnoses

Injury, Risk for related to drowsiness and dizziness secondary to effects of medication
Gas exchange, Risk for Impaired related to respiratory secretions
Knowledge, Deficient related to drug action and side effects.

Planning: Patient Goals and Expected Outcomes The patient will:

Remain free of physical injury
Demonstrate knowledge of drug therapy and side effects
Remain demonstrate relief of symptoms of allergic reaction Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor vital signs before, during, and after administration (due to anticholinergic effect on vital signs of decreased BP and increased heart rate).

Advise patient:

That blood pressure may decrease and heart rate increase
To report changes in vital signs to health care provider
To monitor blood pressure and pulse
Obtain history of narrow angle glaucoma and increased intraocular pressure. (Drug may worsen condition.)
Instruct patient to report history of glaucoma to health care provider.
Obtain history of prostatic hypertrophy and bladder neck obstruction. (Both conditions are contraindicated for use with diphenhydramine due to exacerbation by anticholinergic effects and muscarinic blockade.)
Instruct patient to report any urinary obstruction or difficulty in voiding.
Monitor for respiratory conditions. (Drug may worsen conditions such as asthma.)

Instruct patient to:

Report symptoms of respiratory distress to the health care provider
Increase fluid intake to make expectoration easier
Monitor for GI conditions and distress. (Drug interferes with function of H receptors.)
Advise patient to take medication with food to reduce gastrointestinal distress.

Nursing Process Focus: Patients Receiving Fexofenadine (Allegra)

Assessment Prior to administration

Obtain complete health history including allergies, drug history an possible drug interactions
Assess for presence/history of seasonal allergic rhinitis, allergic conjunctivitis, urticaria, angioedema
Obtain vital signs

Potential Nursing Diagnoses

Injury, Risk related to drug related drowsiness
Knowledge Deficient, related to drug action and side effects

Planning: Patient Goals and Expected Outcomes The patient will:

Demonstrate understanding of drug therapy
Remain free of physical injury Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor neurological status of elderly patients. (The elderly are more prone to syncope, sedation and dizziness due to long acting effects of medication.)

Advise patient to:

Avoid driving or operating heavy machinery until drowsiness is no longer a problem
Resort symptoms of over sedation to health care provider
Monitor respiratory status prior to therapy (due to anticholinergic effects on respiratory system).
Instruct patient to report any difficulty in breathing to health care provider
Monitor for renal impairment. (Use with caution in these patients due to aggravating factors related to muscarinic blockade.)
Advise patient to report changes in urinary pattern or output.
Observe for allergic conditions, such as seasonal allergic rhinitis, allergic conjunctivitis, and urticaria (to monitor effectiveness of drug therapy).
Instruct patient to report changes in allergic condition to health care provider.
Monitor vital signs, especially heart rate and respiratory rate.

Advise patient to:

Not take any OTC cold medications without first checking with the health care providerhealth care provider
Abstain from the use of alcohol while taking this medication 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 Fluticasone (Flonase)

Assessment Prior to administration

Obtain complete health history including allergies, drug history and possible drug interactions
Assess for presence or history of seasonal allergic rhinitis
Obtain vital signs

Potential Nursing Diagnoses

Injury, Risk for related to adverse effects of medication
Knowledge, Deficient related to drug action and side effects

Planning: Patient Goals and Expected Outcomes

The patient will:

Remain free of physical injury
Demonstrate understanding of drug therapy
Demonstrate ability to adminster medication appropriately Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor respiratory function. (Drug worsens respiratory failure, asthma attacks.)
Instruct patient to immediately report signs of respiratory distress to the health care provider.
Monitor for concurrent use of systemic corticosteroids. (Can lead to suppression of adrenal function.)
Instruct patient to completely disclose all other medications he/she is taking.
Monitor for signs of infections. (Use with caution in patients with: tuberculosis, untreated fungal, bacterial or viral infections due to possible development of superinfection; ocular herpes simplex due to worsening of symptoms due to immune suppression.)
Instruct patient to report signs of infection to the health care provider.
Monitor for signs and symptoms of hypercorticism such as acne and hyperpigmentation (due to adrenal insufficiency).
Advise patient to inform health care provider if any weight gain, severe skin conditions occur, hyperactivity.
Provide humidification (to decrease crusting and drying of nasal passages).

Instruct patient:

To report irritation of nasal passages to health care provider
To wash cap and nosepiece with warm water after each use
That transient burning of the nasal passages as well as sneezing are common side effects

Nursing Process Focus Patients Receiving Oxymetazoline (Afrin)

Assessment Prior to administration:

Obtain complete health history including allergies, drug history and possible drug interactions
Assess for presence or history of nasal congestion due to allergic conditions, nasal surgery, middle ear infections (treatment and prevention)

Potential Nursing Diagnoses

Injury, Risk for (nosebleed) related to adverse effects of medication
Tissue Perfusion, Risk for Ineffective related to adverse effects of medication
Knowledge, Deficient related to drug action, side effects, and administration

Planning: Patient Goals and Expected Outcomes The patient will:

Demonstrate an ability to use a nasal inhaler.
Remain free of physical injury
Maintain effective tissue perfusion
Demonstrate knowledge of drug therapy Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Evaluate pupil size and respiratory status before administration. (Drug stimulates alpha1-adrenergic receptors that may cause constricted pupils and respiratory depression.)

Inform patient:

That pupil constriction and respiratory depression may occur
To immediately report respiratory distress to the health care provider
Obtain history of diabetes mellitus (Use cautiously in these patients due to possible interaction of drug with glucose-lower agents.)

Instruct patient:

To monitor their glucose levels frequently when on this medication
To notify their health care provider for any abnormalities in their results.
May need increased doses of glucose- lowering agents
Monitor compliance with medication regimen. (Rebound congestion will occur if medication is used for longer than 5 days due to prolonged use, patient must use more and larger doses of drug.)

Instruct patient:

Not to use medication longer than 5 days.
To notify health care provider if rebound congestion occurs
In proper technique for administering nose drops
To wash hands before and after using nose drops
To rinse dropper in hot water after each use

Obtain history hyperthyroidism (Use cautiously in patients with hyperthyroidism due to central nervous system stimulation by drug’s effect that possibility would cause an exacerbation of the disease process.) - Instruct patient to report nervousness, shaking, tremors, fever, rapid heart beat and breathing to the health care provider.
Monitor vital signs, especially pulse and respiration. (Drug has cardiovascular effects by stimulation of alpha1- adrenergic receptors.)

Advise patient to:

Use only the prescribed amount
Monitor blood pressure at same time daily and record.
Report any abnormal results to 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”).

Monitor neurological status. (Drug may cause cerebral hemorrhage.) - Instruct patient to immediately report the first signs of severe headache.

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 Celecoxib Assessment Prior to administration:

Obtain complete health history including allergies, drug history and possible drug interactions.
Assess for presence/history
- Rheumatoid arthritis
- Osteoarthritis
- Congestive heart failure
- Hypertension
- Renal disease
- Pregnancy
- assess renal function tests, e.g. BUN, creatinine levels

Potential Nursing Diagnoses

Injury, Risk for (Gastrointestinal bleeding) related to adverse effects of the medication
Mobility, Impaired physical related to joint disease
Knowledge Deficient, related to drug action and side effects

Planning: Patient Goals and Expected Outcomes The patient will:

Avoid evidence of gastrointestinal bleeding
Demonstrate compliance with lifestyle modifications necessary for successful medication therapy.
Demonstrate knowledge of drug action and side effects of drug Implementation Interventions and (Rationales) Patient Education/Discharge Planning
Monitor for congestive heart failure, fluid retention, hypertension, and renal disease. (Use cautiously in these patients, as drug may cause increased edema and fluid retention.)
Monitor vital signs (especially pulse and blood pressure) for baseline information and to monitor the drug’s possible effect of COX 1 inhibition on renal vasodilation.

Advise patient to:

Report any difficulty breathing to the health care provider immediately
Report to the health care provider immediately, any blood in the stool, any swelling or skin rash or any yellow coloration to the eyes or skin
Monitor intake and output (due to possible drug interactions that may decrease function of reabsorption of water at the loop of Henle).
Instruct patient to report changes in urinary output to the health care provider.

Monitor for gastrointestinal distress such as nausea, diarrhea, abdominal pain, or flatulence. - Advise patient to take medication with food if gastrointestinal distress is a problem.
Monitor liver function, complete blood count, BUN, serum creatinine, and serum electrolytes. - Instruct patient to keep all appointments for laboratory tests.
Monitor lithium levels in patients who are taking lithium. (Celecoxib may alter established lithium levels.) - Encourage patients to comply with lithium serum levels lab tests as ordered by 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”).

Nursing Diagnoses & Interventions for Medication Therapy: Patient Goals & Outcomes, Study notes of Nursing

Related documents

Partial preview of the text

Download Nursing Diagnoses & Interventions for Medication Therapy: Patient Goals & Outcomes and more Study notes Nursing in PDF only on Docsity!