ࡱ> +-()*` jbjbjss .b 0000000Dwww8wx|DOzzzzzc{c{c{$%h0c{c{c{c{c{00zz c{60z0zc{V00z|z =ZPwL0Ob8EKEE0 c{c{c{c{c{c{c{CRc{c{c{Oc{c{c{c{DDD8?7DDD?DDD000000 Nursing Process Focus: Patients Receiving Ethinyl Estradiol With Norethindrone (Ortho-Novum) Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions Assess for presence/history of pregnancy, thrombophlebitis, CVA, breast cancer Obtain history of smoking Obtain vital signs Potential Nursing Diagnosis Anxiety, related to concern about medication failure with resultant pregnancy, imbalances in hormones Comfort, impaired, related to side effects of medication Health maintenance, ineffective, related to lack of knowledge or understanding of positive health practices (smoking cessation, etc.) Knowledge, deficient, related to no prior contact with oral contraceptives Nutrition, imbalanced, either less than or more than body requirements, related to imbalance in hormone make-up of oral contraceptionPlanning: Patient Goals and Expected Outcomes Patient will: Demonstrate compliance with medication regimen Avoid pregnancy Remain free of side effects Demonstrate knowledge of drug therapy and potential side effectsImplementationInterventions and (Rationales) Patient Education/Discharge PlanningMonitor for pregnancy. (Medication must not be administered to woman who is pregnant. Medication is teratogenic.)Teach patient: That she must have had negative pregnancy test within 2 weeks prior to beginning medication To immediately have pregnancy test if pregnancy is suspected during therapyMonitor for breast or other estrogen-dependent tumors. (Estrogen in medication may cause tumor growth or proliferation.)Teach patient to: Give full medical and family medical history prior to beginning therapy Report to health care provider immediately if 1st degree relative is diagnosed with any estrogen-dependent tumorObserve for thrombophlebitis or other thromboembolic disease. (Estrogen-containing medications predispose a woman to thromboembolism.)Advise patient of signs of possible thromboembolic event, and to immediately report: pain in calves, limited movement in legs, dyspnea, sudden severe chest pain, anxiety, fear.Monitor for cardiac disorders. (Medication will lead to worsening of cardiac problems.)Advise patient of signs of possible cardiac problems which must be immediately reported: chest pain, dyspnea, edema, tachycardia or bradycardia, palpitations.Monitor for cerebrovascular disorders. (Medication increases risk for thrombotic disorders, one of leading causes of CVA.) Teach patient: To contact all health care providers prior to starting oral contraception so other medications can be adjusted as needed Signs of impending migraine headache or seizure, so preventative measures can be takenObtain history of cigarette smoking. (Combination of oral contraception and smoking greatly increases risk of cardiovascular disease, especially MI Risk increases with age >35 and with number of cigarettes smoked, e.g., 15 or more/day.)Advise patient to: Stop smoking prior to beginning treatment with oral contraceptives Attend smoking cessation groups.Monitor mental status. (Side effects such as weight gain may cause depression in some women.)Instruct patient regarding symptoms of depression to report immediately: lack of interest in every-day activities, changes in sleeping or eating habits, stopping previously enjoyable activities, etc.Monitor blood glucose in patients with diabetes. Use with caution in woman with diabetes or with familial history of diabetes. (Combination may upset glycemic control so patient would experience either hypo- or hyper-glycemia; adjustments in dose of hypoglycemic medications may be necessary.)Advise patient to monitor urine and blood glucose regularly, and contact health care provider if any abnormalities occur so adjustments in hypoglycemic medication can be made. Monitor for side effects or adverse reactions. (If serious side effects occur, patient may need to switch to oral contraceptive with a different combination or percentage of hormones.)Advise patient to: Be aware of edema, unexplained loss of vision, diplopia, intolerance to contact lens, nausea, gall bladder disease, diarrhea or constipation, abdominal cramps, changes in urinary function, dysmenorrhea, breast fullness, fatigue, skin rash, acne Note mid-cycle breakthrough bleeding, vaginal candidiasis, photosensitivity, changes in urinary patterns, feelings of abdominal fullness Monitor whether patient understands how/when to take medication. (Only with thorough understanding will she be able to take medication correctly and avoid adverse reactions, or be aware of physical changes that could be secondary to the medication, and take measures to prevent permanent, serious harm.)Advise patient to: Use barrier contraceptive during 1st week of initial cycle and for 7 days after 2 consecutive missed doses Discontinue medication and notify health care provider if bleeding resembling menstrual cycle occurs mid-cycle Be aware of fluid retention (teach to weigh self weekly and record, note tightening of rings, shoes, etc.) Decrease salt intake if edema occurs Contact health care provider if 2 consecutive periods are missed; pregnancy may have occurred Follow recommendations for follow-up Do self breast exams monthly Have annual PAP smears done. See health care provider at regular intervalsEvaluation 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 Conjugated Estgrogens (Premarin) and Conjugated Estrogens with Medroxyprogesterone (Prempro) ASSESSMENT Prior to administration: Obtain complete health history including allergies, drug history and possible drug intgeractions Assess for presence/history of breast cancer, estrogen dependent cancer, abnormal genital bleeding, thromboembolic disorders, cardiovascular disorders, smoking history, pregnancyPOTENTIAL NURSING DIAGNOSES Body image, disturbed, related to side effects of medication Comfort, impaired, related to effects of medication Fluid volume, excess, related to edema secondary to medication Noncompliance, related to unpleasant side effects, desire for pregnancy, lack of knowledge or understanding of proper self-administration Tissue perfusion, impaired, cardiopulmonary, related to development of thrombophlebitis, pulmonary embolism, or cerebral, related to incidence of CVA secondary to medicationPLANNING: PATIENT GOALS AND EXPECTED OUTCOMES Patient will: Demonstrate understanding of correct self administration and potential side effects Demonstrate positive body image and self-concept Remain compliance with drug regimen Remain free of symptoms of thrombophlebitis or other clot developmentImplementation Interventions and (Rationales) Patient Teaching/Discharge PlanningObtain history of cancer in patient or close relative. (Estrogen-dependent cancer combination of medication and estrogen-dependent tumors, either currently or history of, put patient at much higher risk for developing cancer.)Advise patient of importance of complete physical exam prior to beginning therapy with conjugated estrogen.Monitor for signs of pregnancy. (Can cause serious fetal harm.)Instruct patient to Have negative pregnancy test no more than 2 weeks prior to beginning conjugated estrogen therapy and periodically during treatment Report immediately if she suspects she is pregnantMonitor for current or past history of thromboembolism. (Estrogen use increases chance of thromboembolism occurring.)Advise patient of importance of complete disclosure of past medical history.Monitor for undiagnosed abnormal uterine bleeding. (Can increase bleeding, tumor size, if undiagnosed tumor present.)Instruct patient to have complete physical exam prior to beginning therapy.Monitor for cardiovascular/cerebrovascular disorders. (Must be used with caution in patients with CAD, hypertension, and cerebrovascular disease. Any of these conditions predispose woman to thromboembolic disorders. Cardiovascular side effects are the most serious side effects, and include MI, pulmonary embolism, hypertension, CVA.)Teach patient to: Have complete physical exam prior to estrogen therapy Have routine blood pressure screening; teach that hypertension has no symptoms Inform female patients that atypical symptoms of a MI may be experienced: fatigue, dyspnea, nausea, light-headedness, palpitations, racing heart and to report to health care provider immediately if any of these sensations occurEvaluate breast health. (Use with caution in patient with fibrocystic breast disease, breast nodules, or abnormal mammograms. Can cause worsening of condition. If cancer develops, it is essential to have baseline information with which to make comparisons.)Advise patient of importance of complete physical exam prior to treatment and periodically during treatment.Monitor for vision changes. (Medication may cause worsened myopia or astigmatism, intolerance of contact lenses.)Instruct patient to: Have complete eye exam prior to beginning treatment and periodically during treatment Report if decreased vision occurs, or if intolerance to contact lenses occursObtain smoking history. (Smoking increases risk of cardiovascular disease, especially when in combination with estrogens.)Instruct patient to: Quit smoking Attend smoking cessation programsMonitor for diabetes mellitus. (Estrogens may alter blood glucose levels.)Advise diabetic patient to monitor blood glucose frequently and report if any consistent changes.Monitor for seizure disorder. (Estrogen-induced fluid retention may increase incidence of seizures.)Teach patient to Disclose information if seizure disorder present Consult health care provider of anti-seizure medication prior to beginning estrogen therapy Be extra alert for possibility of seizures occurringObserve for side effects. Side effects are dose dependent, and include: weight gain, edema, nausea/vomiting, abdominal cramps and bloating, acute pancreatitis, appetite changes, skin eruptions, mental depression, decreased libido, headache, fatigue, nervousness.Advise patient of common side effects and to be alert to occurrence of them. Monitor for GU changes. (Can be caused by estrogens: breakthrough bleeding, spotting, changes in amount and/or duration of menstrual flow, amenorrhea during and after use, candida vaginitis.)Advise male patient that he may develop feminine characteristics or become impotent; teach him these will resolve when treatment completed Advise female patient to report any of GU changes.Evaluate patients understanding and proper self-administration. (To ensure patient safety) Instruct patient: Regarding dose, form and frequency of medication To take with food to decrease GI irritation To take daily dose at HS to decrease occurrence of side effects That if cyclic therapy ordered, to take medication for 3 weeks and then omit for 1 week To document menstruation and any problems that occur To report immediately if pregnancy suspected To take lowest effective dose for shortest time period, to decrease chances of side effects developing Risks associated with supplemental estrogensEvaluation 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 Medroxyprogesterone (Provera) Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions. Assess for presence/history of: Pregnancy Dysfunctional uterine bleeding Metastatic endometrial or renal cancer Endometrial hyperplasia Thrombophlebitis or thromboembolic disease Breast cancer Decreased liver or kidney function Depression Epilepsy Asthma Migraine headache Cardiac disordersPotential Nursing Diagnoses Health maintenance, ineffective, related to lack of knowledge or understanding of positive health practices, such as smoking cessation Nausea, related to side effects of medication Nutrition, imbalanced, less than or more than body requirements related to imbalance in hormone make-up Sexual dysfunction, relate to hormonal imbalance Sleep pattern disturbed, insomnia, related to effects of medication Therapeutic regimen management, ineffective, related to knowledge deficit or planned failure of therapyPLANNING: PATIENT GOALS AND EXPECTED OUTCOMES Patient will: Follow medication regime exactly as recommended Remain free of sleep disturbances Remain free of side effects or adverse reactions Demonstrate understanding of side effects and adverse reactions to report Maintain usual sexual function Maintain nutrition at expected level Demonstrate understanding of appropriate lifestyle changesImplementation Interventions and (Rationales) Patient Education/Discharge PlanningMonitor for pregnancy. (Medication must not be administered to woman who is pregnant; will cause serious fetal damage.)Instruct patient that she must have negative pregnancy test within 2 weeks prior to beginning medication.Monitor for seizure disorder. (Fluid retention secondary to medication may increase seizure activity. Use with caution in women with seizure disorders.)Advise patient: Of importance of consulting health care provider who ordered anticonvulsants before beginning this medication Regarding life-style changes that may decrease chances of triggering seizure activity Monitor for hypercalcemia. (Medication may cause increased serum calcium levels, especially if in conjunction with a low daily fluid intake.) Advise patient to: Have regular lab studies performed Increase fluids as way to decrease chance of hypercalcemia occurring Note signs of hypercalcemia and report immediately: deep bone and flank pain, anorexia, nausea/vomiting, thirst, constipation, lethargy, psychoses)Monitor mental status. (Use with caution in women with history of depression. Medication may cause nervousness, insomnia, worsening of depression.)Advise patient and caregivers regarding symptoms of depression to note and report: changes in eating and sleeping habits, disinterest in every-day activities, failure to perform ADLs, etc.Evaluate patients knowledge level. (Informed patient will comply more fully with administration regime, and be more aware of and alert to adverse reactions.)Instruct patient: How and when to take medication, and importance of taking exactly as ordered if being used for contraception Proper self-administration if being taken as cancer therapy Regarding symptoms of hypercalcemiaMonitor for side effects: amenorrhea, nausea, jaundice, dizziness, headache, signs of pulmonary embolism (sudden severe chest pain and dyspnea), edema, weight gain. Report immediatelyInstruct patient to: Monitor for side effects and to report to health care provider if they occur Monitor for edema or weight gain by weighing self weekly and recording; noting if rings or shoes become tightObserve foreskin changes caused by reactions to medication. Instruct patient: To monitor for pruritis, urticaria, acne, rash, hirsutism, alopecia That these changes are temporary and will improve upon discontinuation of this medicationEvaluation of Outcome Criteria Evaluate effectiveness of drug therapy by confirming patient goals and expected outcomes have been met (see Planning). Nursing Process Focus: Patients Receiving Oxytocin Assessment Prior to administration: Obtain complete health history including complete past and present gynecological and obstetric history Obtain drug history to determine possible drug interactions and allergies Obtain vital signs Asses fetal monitoringPotential Nursing Diagnosis Comfort, Impaired related to strong uterine contractions Excessive fluid volume Injury, Risk for to fetus related to effect of drug on uterine contractionsPlanning: Patient Goals and Expected Outcomes Patient will Demonstrate increase in force and frequency of uterine contractions and/or let down of milk for breastfeeding. Demonstrate understanding of the drugs action by accurately describing drug side effects and precautions. Demonstrate need to report effects such as listlessness, headache, confusion, anuria, hypotension, nausea, vomiting, and weight gain.ImplementationInterventions and (Rationales)Patient Education/Discharge PlanningAdminister IV medication through infusion device (To maintain accurate dosing)Inform patient regarding the need for equipment.Monitor fetal heart rate. (Increase in force and frequency of uterine contractions may cause fetal distress.)Instruct patient about the purpose and importance of fetal monitoring.Monitor maternal status including BP, pulse, and frequency, duration and intensity of contractions and pain. (Initial administration of mediation may cause a drop in blood pressure. High doses may increase duration and intensity of contractions and increase pain level)Instruct patient about the importance of monitoring maternal status.Monitor fluid balance. (Prolonged IV infusion may cause water intoxication.)Instruct patient to report symptoms of water intoxication including drowsiness, listlessness, headache, confusion, anuria, or weight gain.Monitor for post partum/post abortion hemorrhage. Instruct patient: About the importance of being monitored frequently after delivery or after abortion To report severe vaginal bleeding or increase in lochiaEvaluation 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 Testosterone Base (Andro and Others) Assessment Prior to administration: Obtain complete health history including allergies, drug history and possible drug interactions. Assess for presence/history of hypogonadism, secondary sex characteristics, increased or decreased libido, low sperm count, impotence Monitor history of cardiovascular diseasePotential Nursing Diagnosis Body image, disturbed, related to lack of normal sexual development, impotence, decreased sperm count, growth retardation, gynecomastia, virilism in females Coping, ineffective, related to delayed sexual development and inability to accept this Family processes, interrupted, related to males inability to function sexually and/or inability to impregnate partner Identity, disturbed personal, related to lack of secondary sex characteristics expected in pubertal boy Sexual dysfunction, related to lack of normal amounts of androgenPlanning: Patient Goals and Expected Outcomes Patient will: Experience improvement of underlying condition for which testosterone ordered, without worsening of underlying condition, with few side effects and no adverse reactions Demonstrate understanding of how/why he/she is taking medication and desired effects Demonstrate improved body image as effectiveness of medication is established Experience return of usual sexual functionImplementation Interventions and (Rationales) Patient Education/Discharge PlanningMonitor for prostatic or male breast cancer. (Testosterone will worsen either condition.)Instruct patient to: Have complete medical exam including PSA tests prior to taking testosterone and periodically during therapy Note and report any symptoms of altered urinary function: retention, hesitancy, nocturia, hesitancy, frequency, dribblingMonitor for serious renal disease. (Edema caused by testosterone and added stress placed on the kidneys.)Instruct patient to: Have renal function tests, BUN, creatinine performed prior to testosterone therapy and periodically during therapy Report immediately any symptoms of kidney dysfunction: decreased urination, edema, uremic frost, confusion, etc.Monitor for decreased cardiac function. (Edema caused by testosterone stresses the heart.)Instruct patient to: Have cardiac function tests performed prior to and periodically during therapy Immediately report symptoms of decreased cardiac function: general weakness, fatigue, dyspnea, and edemaMonitor serum cholesterol levels. (Elevated cholesterol levels secondary to testosterone administration may increase patients risk of cardiovascular disease.)Instruct patient: To have cholesterol levels measured prior to and periodically during therapy Regarding lifestyle modifications which may lower risk of hypercholesterolemia: low fat diet, increased exercise, decrease consumption of red meat, butter, fried foods, etc.If patient is female, monitor for pregnancy or lactation. (Testosterone crosses into breast milk and may cause damage to infant, including masculinization of female infant.)Instruct patient: To have negative pregnancy test within 2 weeks before initiating testosterone therapy and monthly during therapy Regarding the importance of reliable birth control during testosterone therapyMonitor for hypercalcemia. (Hypercalcemia in patient with metastatic breast cancer usually indicates bone metastasis.) Instruct patient: To have lab studies performed prior to and during therapy About symptoms of increased serum calcium and to report immediately if the following occurs: deep bone and flank pain, anorexia, nausea/vomiting, thirst, constipation, lethargy, psychosesEvaluate bone growth in children and adolescents. (Premature epiphyseal closing may occur, leading to growth retardation.)Advise patient and caregivers that bone age determinations should be done every 6 months.Monitor fluid intake. (Increased fluids will increase urine production and decrease chance of stone formation.)Advise patient: To consume 3,000-4,000cc fluid daily That urinary output will increase, and not to be alarmed Non-liquids that can be consumed to increase fluid intake: gelatin, popsicles, ice cream, etc.Monitor for diabetes mellitus. (Testosterone therapy may change glucose tolerance.)Instruct patient to: Monitor blood sugar daily and notify health care provider if changes occur Make needed adjustments in hypoglycemic medications and dietEvaluation 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 Sildenafil (Viagra) Assessment Prior to administration: Obtain complete health history including hematologic disorders, cardiac, kidney or liver disease, and anatomic deformities Obtain drug history, specifically organic nitrates and nitroglycerin, to determine possible drug interactions and allergiesPotential Nursing Diagnosis Body image, Disturbed related to impaired sexual function Sexual dysfunction related to known or unknown cause Sensory perception, disturbed, visual related to disease process.Planning: Patient Goals and Expected Outcomes Patient will: Report more positive body image during drug therapy Report normal sexual function Demonstrate understanding of the drugs action by accurately describing side effects and precautions, and importance of follow-up careImplementationInterventions and (Rationales)Patient Teaching/Discharge PlanningMonitor cardiovascular status. (Patient who has 1st attack of angina during time he is taking sildenafil should not receive any nitrate products. Instruct patient and/or caregiver to: Carry identification stating he is taking Sildenafil, so he will not be given nitrates Recognize the importance of EKG monitoring periodically during therapy Have vital signs, including BP, checked routinely during therapy with slidenafil Recognize CV risk factors and modify: smoking, high fat/high cholesterol diet, lack of exercise, obesity, Type A personality, high stress lifestyleMonitor sexual response to include: *Frequency, firmness, maintenance of erections; *Frequency of orgasms *Frequency, satisfaction and enjoyment of sexual activity; *Satisfaction with sexual relationshipInstruct patient and/or caregiver to: Keep diary R/T use of sildenafil, sexual response, any cardiovascular symptoms that may occur Report any changes to health care provider Seek emergency care if erection lasts longer that 4 hours.Monitor diet. (High fat meals can delay absorption of sildenafil and delay onset of action by 1 hour. Taking sildenafil with grapefruit juice may lead to increased serum sildenafil levels, leading to adverse effects.)Instruct patient and/or caregiver to: Avoid administration of Sildenafil with meals, especially high-fat meals Avoid grapefruit juice when administering Sildenafil Monitor patient knowledge and understanding. 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