ࡱ> ]_Z[\` 9bjbjss .`iiiiijlllllmmm>@@@@@@$ahdMmmmmmdllxxxmzll>xm>xxLll utPisjZ<0{u{{ mmxmmmmmddx mmmmmmmdFNN Nursing Process Focus: Patients Receiving Phenelzine (Nardil) Assessment Prior to administration: Obtain complete medical history including allergies, neurological , cardiac, renal, biliary, and mental disorders including blood studies: CBC, platelets and liver enzymes,. Obtain patients drug history to determine possible drug interactions and allergies Obtain 24 hour dietary history to identify tyramine containing foods ingested recently Assess neurological status, including identification of recent mood and behavioral patternsPotential Nursing Diagnoses Sorrow, Chronic related to depressive state. Thought Processes, Disturbed related to effects of drug therapy Adjustment, Impaired related to inadequate drug effectiveness. Knowledge, Deficient, related to drug action and side effects. Suicide, Risk for related to inadequate drug effectiveness. Hopelessness related to emotional state.Planning: Patient Goals and Expected Outcomes The patient will Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Implementation Interventions and (Rationales) Patient Education/Discharge PlanningMonitor vital signs, especially pulse and blood pressure. (Phenelzine may cause orthostatic hypotension.) Instruct the patient to immediately report: Any change in sensorium particularly impending syncope. Avoid abrupt changes in posture; rise slowly from prolonged periods of sitting/lying down. Monitor vital signs (especially blood pressure) ensuring proper use of home equipment. Consult the health care provider regarding "reportable" blood pressure readings (e.g. "lower than 80/50). Monitor cardiovascular status. Observe for hypertensive crisis and signs of impending stroke or M.I.: severe headache, dizziness, paresthesias, bradycardia, tachycardia, nausea/vomiting, diaphoresis. Instruct patient to immediately report severe headache, dizziness, paresthesias, bradycardia, tachycardia, nausea/vomiting, diaphoresis. Monitor neurological status. Observe for changes in LOC and seizures. Use with caution in epilepsy. (MAOIs may reduce the seizure threshold.)Instruct patient to report significant changes in neurological status, such as seizures, extreme lethargy, slurred speech, disorientation or ataxia. Monitor mental and emotional status. Observe for suicidal ideation. Therapeutic benefits may take 2-6 weeks. Interview patient regarding suicide potential; Obtain a "no-self harm" verbal contract from the patient. Instruct the patient to immediately report dysphoria or suicidal impulses. Monitor kidney and liver function. Observe for signs of hepatic toxicity. Monitor laboratory blood work such as platelets, PT, PTT, and liver enzymes. Assess urinary output and edema in feet/ankles. (Medication is excreted through the kidneys. Long term use may lead to renal dysfunction.) Monitor CBC, BUN, creatinine, and urinalysis.Instruct the patient to: Report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness or distention, or change in color of stool Adhere to a regular schedule of laboratory testing for liver function as ordered by the health care provider. Report changes in urination, flank pain or pitting edema immediately.Ensure patient safety. (Dizziness caused by postural hypotension increases the risk of fall injuries.) Raise bed rails. Place call bell within patient's reach. Instruct the patient to: Call for assistance before getting out of bed or attempting to ambulate alone. Avoid driving or other activities requiring mental alertness or physical agility until blood pressure is stabilized and effects of the medication are known. Teach pt to wear/carry identification stating taking MAOI. 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 Imipramine (Tofranil) Assessment Prior to administration: Obtain complete medical history including allergies, neurological , cardiac (including recent MI) renal, biliary, and mental disorders including EKG and blood studies: CBC, platelets, BUN, creatinine, liver enzymes and urinalysis. Obtain patients drug history to determine possible drug interactions and allergies Assess neurological status, including seizure activity and identification of recent mood and behavioral patternsPotential Nursing Diagnoses Sorrow, Chronic related to disease process Thought Processes, Disturbed related to effects of drug Adjustment , Impaired related to inadequate drug therapy Knowledge Deficient , related to drug action and side effects Suicide, Risk for related to inadequate drug therapy Urinary retention related to side effects of drug  Planning: Patient Goals and Expected Outcomes The patient will Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Maintain normal urinary flowImplementationInterventions and (Rationales)Patient teaching/discharge planningMonitor vital signs especially pulse, and blood pressure. (Imipramine may cause orthostatic hypotension.) Instruct the patient to immediately to: Report any change in sensorium particularly impending syncope. Avoid abrupt changes in posture; rise slowly from prolonged periods of sitting/lying down. Monitor vital signs (especially blood pressure) ensuring proper use of home equipment. Consult the health care provider regarding "reportable" blood pressure readings (e.g. "lower than 80/50). Monitor cardiovascular status. Observe for hypertension and signs of impending stroke or M.I and heart failure. Use with caution in cardiac patients. Instruct the patient to immediately report severe headache, dizziness, paresthesias, bradycardia, chest pain, tachycardia, nausea/vomiting, diaphoresis or other distressing symptoms.. Monitor neurological status. Observe for somnolence and seizures. (Imipramine causes somnolence related to CNS depression. Use with caution in epilepsy. Imipramine may reduce the seizure threshold.)Instruct patient to Report significant changes in neurological status, such as seizures, extreme lethargy, slurred speech, disorientation or ataxia. Take dose at bedtime to reduce daytime sedation. Monitor mental and emotional status. Observe for suicidal ideation. Therapeutic benefits are delayed. Out-patients should have no more than a 7-day medication supply. Monitor for underlying mental disease such as schizophrenia or bipolar disorders. (Imipramine may trigger manic states.) Interview patient regarding suicide potential; Obtain a "no-self harm" verbal contract. Instruct the patient: That it may take 10-14 days before any improvement is noticed, and about a month to achieve full therapeutic effect. To immediately report dysphoria , sleep-wake cycle changes or suicidal impulses.Monitor renal status Monitor urinary output. (May cause urinary retention due to muscle relaxation in urinary tract. Imipramine is excreted through the kidneys. Impaired kidney function may result in reduced medication clearance and increased serum drug levels. Urinary retention may exacerbate existing symptoms of prostatic hypertrophy.)Instruct patient or caregiver to Measure and monitor fluid intake and output. Notify the health care provider of the following: edema, dysuria (hesitancy, pain, diminished stream), changes in urine quantity or quality (eg. cloudy, with sediment) Report fever or flank pain that may be indicative of a urinary tract infection related to urine retention. Monitor gastrointestinal status. Observe for abdominal distention. (Muscarinic blockade reduces tone and motility of intestinal smooth muscle, and may cause paralytic ileus.) Instruct the patient to Exercise, drink adequate amounts of fluid and add fiber to the diet to promote stool passage. Consult the health care provider regarding a bulk laxative or stool softener if constipation becomes a problem. Monitor liver function. Observe for signs and symptoms of hepatic compromise. Monitor blood studies including CBC, differential, platlets, PT, PTT and liver enzymes. Instruct the patient to: Report nausea, vomiting, diarrhea, rash, jaundice, epigastric or abdominal pain, tenderness, or change in color of stool. Adhere to laboratory testing regimen for blood tests and urinalysis as directed.Monitor hematologic status. Observe for signs of bleeding. (Imipramine may cause blood dyscrasias. If given in hyperthyroidism, can cause agranulocytosis.) Monitor laboratory blood work (see previous box). Use with warfarin may increase bleeding time.Have patient Report the following: excessive bruising, fatigue, pallor, shortness of breath, frank bleeding and/or tarry stools. Demonstrate guiac testing on stool for occult blood.Monitor immune/ metabolic status. Use with caution in patients with diabetes mellitus and hyperthryroidism. (Imipramine may either increase or decrease serum glucose.)Instruct patients with diabetes to: Monitor glucose level daily. Consult health care provider regarding reportable serum glucose levels (eg. "less than 70 and more than 140"). Monitor for adverse drug effects and overdosage. Observe for extrapyramidal and anticholinergic effects. (In overdosage, 12 hours of anticholinergic activity is followed by CNS depression. Cardiac dysrthymia may also occur.) Do not treat overdosage with quinidine, procainamide, atropine or barbiturates. Use of these drugs potentiate cardiac depression. Instruct the patient/caregiver: To immediately report involuntary muscle movement of the face or upper body (e.g. tongue spasms), fever, anuria, lower abdominal pain, confusion, anxiety, hallucinations, psychomotor agitation, visual changes, excessively dry mouth and difficulty swallowing. That mild dry mouth may be relieved by (sugar-free) hard candies, chewing gum and drinking fluids. To avoid alcohol containing mouthwashes which can further dry oral mucous membranes. Monitor visual acuity. Use with caution in narrow-angle glaucoma. (Imipramine may cause an increase in intraocular pressure. Anticholinergic effects may produce blurred vision.)Instruct the patient to Report any disturbing visual changes, headache or eye pain. Inform eye care professional of imipramine therapy.Ensure patient safety. (Dizziness caused by postural hypotension increases the risk of fall injuries.). Raise bed rails. Place call bell within patient's reach. Instruct the patient to: Call for assistance before getting out of bed or attempting to ambulate alone. Avoid driving or other activities requiring mental alertness or physical agility until blood pressure is stabilized and effects of the medication are knownUse cautiously with the elderly or young. (Diminished kidney and liver function related to aging can result in higher serum drug levels, and may require lower doses. Children, due to an immature CNS, respond paradoxically to CNS-active drugs.)Instruct the patient/caregiver that the elderly may be more prone to side effects such as hypertension and dysrythmias. Children on imipramine for nocturnal enuresis may experience mood alterations. 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 FLUOXETINE (Prozac) Assessment Prior to administration: Obtain complete medical history including allergies, neurological, psychological, cardiac, renal, and liver disorders(including recent history of seizures or suicidal ideation) and including blood studies: glucose, BUN, creatinine, electrolytes, liver function tests Obtain patients drug history to determine possible drug interactions and allergiesPotential Nursing Diagnoses Body image disturbed, related to weight gain Anxiety, related to drug effect Coping, Ineffective related to inadequate drug therapy Knowledge Deficient, related to drug action and side effects, Suicide, Risk for related to early drug therapy Powerlessness, related to depressive state. Planning: Patient Goals and Expected Outcomes The patient will Report mood elevation and will effectively engage in activities of daily living. Report an absence of suicidal ideations and improvement in thought processes. Demonstrate a decrease in anxiety (e.g. ritual behaviors). Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. ImplementationInterventions and (Rationales)Patient Education/Discharge PlanningObserve for Serotonin Syndrome (SS), a medical emergency. (Serotonin Syndrome is possible at high doses, and especially combined with MAOIs.) For suspected SS, stop the drug and initiate supportive care: monitor all vital signs, including EKG. Inform the patient/caregivers: That overdosage may result in serotonin syndrome, which can be life-threatening. To seek immediate medical attention for the following: dizziness, headache, tremor, nausea/vomiting, anxiety, disorientation, hyperreflexia, diaphoresis and fever. Monitor mental and emotional status. Observe for suicidal ideation (Therapeutic benefits may take a month or more for ideal response). Monitor for presence of underlying or concomitant mental disorders such as schizophrenia or bipolar disorders. (Fluoxetine may trigger mania.) Interview patient regarding suicide potential; obtain a "no-self harm" verbal contractInstruct the patient: That it may take 10-14 days before any improvement is noticed, and about a month to achieve full effect. To immediately report dysphoria , sleep-wake cycle changes or suicidal impulses.Monitor neurological status. Observe for seizures. Use with caution in epilepsy. (Fluoxetine decreases the seizure threshold.) Instruct patient that if seizures occur, stop the drug and contact the health care provider immediately. Monitor sleep-wake cycle. Observe for insomnia and/or daytime somnolence. Instruct the patient with insomnia to: Take the drug very early in the morning to promote normal timing of sleep onset. Avoid driving or potentially hazardous activities until effects of drug are known. Take medication at bedtime if daytime drowsiness persists. Monitor kidney and liver function by laboratory tests such as CBC, BUN, creatinine, PT, PTT, liver enzymes and urinalysis. (Fluoxitene is slowly metabolized and excreted, increasing the risk of organ damage. Impaired organ function can further increase drug levels.)Advise the patient to inform the health care provider of the following: nausea, vomiting, diarrhea, rash, jaundice, flank/abdominal pain or tenderness, changes in urinary quantity and quality or in stool color. Monitor metabolic status. Use with caution in diabetics. (Fluoxitene may cause hypoglycemia initially, and hyperglycemia with drug withdrawal. Fluoxitene may also cause initial anorexia and weight loss, but with prolonged therapy may result in weight-gain of up to twenty pounds.)Instruct diabetic patients to: Monitor glucose level daily and consult health care provider regarding reportable serum glucose levels (eg. "less than 70 and more than 140"). Instruct the patient that anorexia and weight loss will diminish with continued therapy.  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 Lithium (Eskalith) Nursing Process Focus Patients Receiving Lithium (Eskalith) Assessment Prior to administration: Obtain complete health history including allergies, drug history, and possible drug interactions. Assess mental and emotional status, including any recent suicidal ideation. Obtain cardiac history (including) EKG and vital signs; renal, and liver disorders, and blood studies: glucose, BUN, creatinine, electrolytes, and liver enzymes.Potential Nursing Diagnoses Risk for Self-Directed Violence related to delusional thinking Disturbed Thought Processes related to disease process Disturbed Sleep Pattern related to manic excitement Sleep Deprivation (in mania) related to manic excitement Risk for Fluid Volume Imbalance related side effect of medication Impaired Social Interaction related to egocentric behaviorPlanning: Patient Goals and Expected Outcomes The patient will: % Demonstrate stabilization of mood, including absence of mania and suicidal depression. % Engage in normal activities of daily living and report subjective improvement in mood. % Demonstrate understanding of drug action by accurately describing drug effects and precautions. ImplementationInterventions and (Rationales)Patient Education/Discharge Planning% Monitor mental and emotional status. Observe for mania and/or extreme depression. (Lithium should prevent mood swings.)% Instruct the patient to keep a symptom log to document response to medication.% Monitor electrolyte balance. (Lithium is a salt affected by dietary intake of other salts such as sodium chloride. Insufficient dietary salt intake causes the kidneys to conserve lithium, increasing serum lithium levels.)Instruct patient to: Monitor dietary salt intake; consume sufficient quantities, especially during illness or physical activity. Avoid activities that cause excessive perspiration. Monitor fluid balance. (Lithium causes polyuria by blocking effects of antidiuretic hormone.) Measure intake and output. Weigh patient daily. (Short-term changes in weight are a good indicator of fluctuations in fluid volume. Excess fluid volume increases the risk of HF; pitting edema may signal HF.)Instruct patient to: % Increase fluid intake to 1 to 1.5 L per day. % Limit or eliminate caffeine consumption (caffeine has a diuretic effect that can cause lithium sparing by the kidneys). % Notify healthcare provider of excessive weight gain or loss, or pitting edema. Monitor renal status. (Lithium may cause degenerative changes in the kidney which increases drug toxicity.) Monitor laboratory tests: CBC, differential, BUN, creatinine, uric acid, and urinalysis. Use with caution in kidney disease.Instruct patient to: % Immediately report anuria, especially accompanied by lower abdominal tenderness, distention, headache, and diaphoresis. % Inform healthcare provider of nausea, vomiting, diarrhea, flank pain or tenderness and changes in urinary quantity and quality (e.g., sediment).Monitor cardiovascular status. (Lithium toxicity may cause muscular irritability resulting in cardiac dysrhythmias or angina.) % Monitor vital signs including apical pulse. % Use with caution in patients with a history of CAD or heart disease. Instruct patient to: % Immediately report palpitations, chest pain, or other symptoms suggestive of myocardial infarction. % Monitor vital signs ensuring proper use of home equipment. % Monitor gastrointestinal status. (Lithium may cause dyspepsia, diarrhea, or metallic taste.)% Instruct patient to take the drug with food to reduce stomach upset and report distressing GI symptoms. % Monitor metabolic status. (Lithium may cause goiter with prolonged use and false-positive results on thyroid tests.)% Instruct patient to report symptoms of goiter or hypothyroidism: enlarged mass on neck, fatigue, dry skin, or edema. Evaluation of Outcome Criteria Evaluate effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning). Nursing Process Focus: Patients Receiving Methylphenidate (Ritalin) Assessment Prior to administration: Obtain complete health history including allergies, drug history, and possible drug interactions. Obtain history of neurological, cardiac, renal, biliary, and mental disorders including blood studies: CBC, platelets, liver enzymes. Assess neurologic status, including identification of recent behavioral patterns. Assess growth and development. Potential Nursing Diagnoses Risk for Delayed Development, related to growth retardation secondary to methylphenidate. Delayed Growth and Development, related to increased motor activity, growth retardation secondary to methylphenidate, unsuccessful interpersonal relationships. Imbalanced Nutrition: Less than Body Requirements, related to side effect of medication. Deficient Knowledge, related to drug therapy. Disturbed Sleep Pattern, related to possible side effect of medication. Planning: Patient Goals and Expected Outcomes The patient will: Experience subjective improvement in attention/concentration and reduction in impulsivity and/or psychomotor symptoms ("hyperactivity"). Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. Implementation Interventions and (Rationales)Patient Education/Discharge Planning% Monitor mental status and observe for changes in level of consciousness and adverse effects such as persistent drowsiness, psychomotor agitation or anxiety, dizziness, trembling, or seizures. % Instruct patient to report any significant increase in motor behavior, changes in sensorium, or feelings of dysphoria. % Use with caution in epilepsy. (Drug may reduce the seizure threshold.)% Instruct patient to discontinue drug immediately if seizures occur and notify healthcare provider. % Monitor vital signs. (Stimulation of the CNS induces the release of catecholamines with a subsequent increase in heart rate and blood pressure.)Instruct patient to: % Immediately report rapid heartbeat, palpitations, or dizziness. % Monitor blood pressure and pulse, ensuring proper use of home equipment.% Monitor gastrointestinal and nutritional status including side effects such as nausea/vomiting, anorexia, and abdominal pain. (CNS stimulation causes anorexia and elevates BMR, producing weight loss.) Instruct patient to % Report any distressing GI side effects. % Take the drug with meals to reduce GI upset and counteract anorexia; eat frequent small nutrient and calorie dense snacks. % Weigh weekly and report losses over one pound. % Monitor laboratory tests such as CBC, differential, and platelet count. (Drug is metabolized in the liver and excreted by the kidneys; impaired organ function can increase serum drug levels. Drug may cause leukopenia and/or anemia.) Instruct patient to: % Report shortness of breath, profound fatigue, pallor, bleeding, or excessive bruising (these are signs of blood disorder). % Report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness, distention, or change in color of stool (these are signs of liver disease). % Adhere to laboratory testing regimen for blood tests and urinalysis as directed.% Monitor effectiveness of drug therapy. Instruct the patient to: Schedule regular drug holidays. Not discontinue abruptly as rebound hyperactivity or withdrawal symptoms may occur: taper the dose prior to starting a drug holiday. Keep a behavior diary to chronicle symptoms and response to drug. Safeguard medication supply due to abuse potential. % Monitor growth and development. (Growth rate may stall in response to nutritional deficiency caused by anorexia.)% Instruct patient that reductions in growth rate are associated with drug usage. Drug holidays may decrease this effect. % Monitor sleep-wake cycle. (CNS stimulation may disrupt normal sleep patterns.)Instruct patient that: % Insomnia may be an adverse reaction. % Sleeplessness can sometimes be counteracted by taking the last dose no later than 4 p.m. % Drug is not intended to treat fatigue; warn the patient that fatigue may accompany wash-out period. 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 CHLORPROMAZINE (Thorazine) Assessment Prior to administration: Obtain complete medical history, especially of mental illness, respiratory, gastrointestinal, genitourinary disorders, alcohol and illegal drug use. Include blood studies: electrolytes, CBC, BUN, creatinine, HCG levels if indicated, and drug screens (for use of illegal drugs) Obtain patients drug history to determine possible drug interactions and allergiesPotential Nursing Diagnoses Therapeutic regimen management, ineffective Activity intolerance, risk for related to side effect of drug Knowledge deficient, related to drug action and side effects Constipation related to decreased intestinal motility Injury, risk for related to drug effects Planning: Patient Goals and Expected Outcomes The patient will: Experience relief of positive symptoms of schizophrenia, and relief of manic symptoms in patients with schizo-affective disorder Demonstrate an understanding of the drugs action by accurately describing drug side effects and precautions, and measures to take to decrease any side effects. Adhere strictly to the recommended treatment Abstain from alcohol and illegal drug use Immediately report any occurrence of any adverse reactionsImplementationInterventions and (Rationales)Patient Education and Discharge PlanningMonitor for EPS and NMS. Medications may be available to treat EPS. (Presence of EPS may be sufficient reason for patient to discontinue chlorpromazine; NMS is life-threatening and must be reported and treated immediately.)Teach patient and family to: Recognize tardive dyskinesia, dystonia, akathesia, pseudoparkinsonism Recognize and seek treatment immediately for elevated temperature, unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and incontinenceMonitor for cheeking, hoarding or sharing medication. Observe patient closely for noncompliance. (If therapeutic results are not seen, patient may not be taking medication as ordered, even though he/she may appear to be taking it.)Teach patient/family: Importance of taking medication exactly as ordered, and not sharing it with anyone How to check to be sure patient has swallowed medicationObserve for side effects such as orthostatic hypotension, constipation, anorexia, GU problems, respiratory changes, visual disturbances. (These side effects are caused by the anticholinergic effects of chlorpromazine.) Instruct patient to: Change position and arise slowly Not to drive a car until he/she is stabilized on chlorpromazine and sedating effects are known Report vision changes Comply with required laboratory tests as ordered, e.g, Thorazine levels, electrolytes, CBC, BUN, and creatinine. Increase roughage in diet, increase fluids, and increase exercise to decrease or avoid constipationMonitor for use of medication. (Medication must be gradually withdrawn over a 2-3 week time, or patient may experience nausea/vomiting, dizziness, tremors, or dyskinesia.)Instruct patient: To continue taking the medication as ordered, even if not therapeutic benefits are felt. That it may take 6 weeks-6 months for full therapeutic benefits. 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(Caffeine will cause a decreased therapeutic response of chlorpromazine.)Instruct patient to avoid caffeine in common products contain caffeine, including: coffee, tea, carbonated beverages, and chocolate.Monitor patients environment. (Chlorpromazine may cause patient to perceive brownish discoloration of objects or photophobia. Chlorpromazine may also interfere with the bodys ability to regulate body temperature.)Instruct patient: Wear dark glasses to avoid discomfort from photophobia Avoid temperature extremes.Observe for evidence of alcohol/illegal drug use. (The patient may use alcohol/illegal drugs as means as coping with symptoms of psychosis.)Instruct the patient to refrain from alcohol/illegal drug use. 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 CLOZAPINE (Clozaril) Assessment Prior to administration: Assess for hallucinations, mental status, dementia, bipolar disorder (initially and throughout therapy). Obtain complete medical history, especially psychological, neurologic and blood diseases: including blood studies: CBC, WBC with differential, electrolytes, BUN, creatinine, liver enzymes. Obtain patients drug history to determine possible drug interactions and allergies.Potential Nursing Diagnoses Anxiety related to disease process Injury, risk for related to effects of drug Noncompliance, related to side effects of drug Sleep pattern, disturbed, related to drug effect Knowledge deficient, related to drug action and side effectsPlanning: Patient Goals and Expected Outcomes The patient will: Report a reduction of psychotic symptoms, including delusions, paranoia, irrational behavior Demonstrate an understanding of the drugs action by accurately describing drug side effects and precautions, and measures to take to decrease any side effects Adhere to recommended therapy, including medications, psychotherapy, health care provider and lab appointments Refrain from alcohol, caffeine, smoking, other CNS depressants ImplementationInterventions and (Rationales)Patient Education and Discharge PlanningMonitor RBC and WBC counts. If WBC levels drop < 3500, medication will need to be stopped immediately. (Patient may be developing agranulocytosis, which could be life-threatening.)Advise patient of the importance of having weekly lab studies done. Monitor for hematologic side effects. (Neutropenia, leukopenia, agranulocytosis, thrombocytopenia may occur, secondary to possible bone marrow suppression caused by clozapine.)Instruct patient to report immediately any sore throat, signs of infection, fatigue, bruising, without apparent cause.Observe for side effects such as drowsiness, sedation, dizziness, depression, anxiety, tachycardia, hypotension, nausea/vomiting, excessive salivation, urinary frequency or urgency, incontinence, weight gain, muscles pain or weakness, rash, fever. Report immediately.Instruct patient to report side effects to the health care provider. Monitor for side effects: mouth dryness, constipation, urinary retention. Urinary retention may be corrected only by use of an indwelling catheter.Inform patient that: Mouth dryness and constipation can be decreased with sugarless gum or candy, increased fluids, frequent sips of water, increased fruits and vegetables in diet If urinary retention occurs, notify health care provider immediately to prevent complicationsMonitor for decrease of psychotic symptoms. (Medication is working as it should if patient exhibits more normal thoughts and behaviors. If patient continues to exhibit symptoms of psychosis, either he is not taking medications as ordered, he is taking an inadequate dose, or he is immune to it and it will need to be discontinued and another anti-psychotic begun.)Teach patient/family to: Look for more normal behaviors (completing own ADLs, showing more interest in surroundings, more normal sleep patterns, etc.), to notice decrease or absence of symptoms of psychosis, including hallucinations, delusions, paranoia, etc. Contact health care provider if no decrease of symptoms occurs over a six week periodMonitor for alcohol use. (Alcohol used concurrently with clozapine will cause increased CNS depression. Patient may decide to stop taking clozapine because he wishes to use alcohol.)Instruct patient: Refrain from alcohol use; refer to Alcoholics Anonymous or another support group if indicated Take medication as ordered; do not stop medication and drink alcoholDiscourage caffeine use. (Use of caffeine-containing substances will negate effects of clozapine.)Inform patient of common caffeine-containing products, including coffee, tea, carbonated beverages, chocolate, etc.Encourage smoking cessation. (Heavy smoking may decrease blood levels of clozapine.)Instruct patient to stop or decrease smoking; refer to smoking cessation programs if indicated.Monitor elderly closely, and give lower doses. (They may be more sensitive to anticholinergic effects.)Teach elderly patients ways to counteract anticholinergic effects of medication, while taking into account any other existing medical problems.Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning). 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