Nursing Process Focus:
Patients Receiving Ranitidine (Zantac)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Injury, Risk for (falls) related to
drowsiness secondary to drug therapy
 Obtain complete health history including
allergies, drug history and possible drug
 Nutrition, Risk for Imbalanced: Less
interactions
than body requirements related to
adverse effects of drug therapy
 Assess for presence/history
gastroesophageal reflux disease, gastric
 Pain, related to gastric irritation
ulcer
secondary to ineffective response to
 Obtain vital signs
drug therapy
 Assess liver and kidney function,
 Knowledge, Deficient related to drug
pregnancy status and complete blood
therapy and side effects
count.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of side effects including abdominal pain, heartburn, jaundice, hematemesis,
and respiratory difficulty.
 Demonstrate understanding of risks and benefits of drug therapy.
 Remain free of physical injury
 Maintain balanced nutrition, and weight within expected levels
Implementation
Interventions and (Rationales)
Monitor serum creatinine, AST, ALT
alkaline phosphatase and total bilirubin.
Patient Education/Discharge Planning

 Advise patient to:
 Report symptoms of liver dysfunction
including jaundice, pruritus, fatigue
 Stop smoking while on drug therapy
 Abstain from alcohol while taking this
medication, as it may potentiate drowsiness
 Monitor for bleeding, bruising, including  Instruct patient to report signs of unusual
complete blood count. (Drug may cause
bleeding such as petechiae or excessive
thrombocytopenia.)
bruising
 Institute safety procedures to protect the  Advise patient not to drive or operate heavy
patient who experiences dizziness.
machinery until the response to drug
therapy can be evaluated.
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 Omeprazole (Prilosec)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Injury, Risk for (fall) related to
drowsiness secondary to drug therapy
 Obtain complete health history including
allergies, drug history and possible drug
 Pain, Risk for related to gastric irritation
interactions
 Nutrition, Risk for Imblance: less than
 Assess for presence/history
body requirements related to ineffective
Gastrointestinal distress, gastrointestinal
response to drug therapy
bleeding
 Assess alcohol use, complete blood
count, renal function, and stool for
occult blood.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of signs of side effects including headache, dizziness, diarrhea, abdominal
pain, hematuria and rash
 Demonstrate understanding of the risks and benefits of drug therapy.
Implementation
Interventions and (Rationales)
Monitor the smoking and food habits of
the patient. (Smoking increases stomach
acid production.)
Patient Education/Discharge Planning
Advise patient to:

 Abstain from alcohol use while taking this
medication
 Refrain from spicy foods, caffeine and
smoking which may increase gastric
irritation
 Monitor elimination pattern. (Drug may
 Advise patient to keep a food diary to help
cause diarrhea.)
correlate symptoms with foods eaten.
 Periodically monitor urine for the
 Instruct patient to report change in urine
presence of blood and/or protein.
color 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”).
Nursing Process Focus:
Patients Receiving Diphenoxylate with Atropine (Lomotil)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Fluid volume, Risk for Imbalance: less
than body requirements related to fluid
 Obtain complete health history including
allergies, drug history and possible drug
loss secondary to diarrhea
interactions
 IMpaired skin integrity, Risk for related
to diarrhea stools
 Assess for presence/history of diarrhea,
dehydration, electrolyte imbalance
 Injury, Risk for (falls) related to
 Assess sodium level, chloride level,
drowsiness secondary to drug therapy
potassium level, stool culture, presence of
 Knowledge, Deficient related to drug
dehydration, vital signs and EKG.
action and side effects
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of instructions necessary for drug therapy.
 Immediately report persistent diarrhea, constipation, abdominal pain, blood in stool,
confusion, dizziness or fever.
Implementation

Interventions and (Rationales)
Monitor abdomen for distention and
degree and location of abdominal pain.
(This may be sign of toxic megacolon.)

Monitor frequency, volume,
characteristics, and consistency of stools.

Offer ice, gum or sour candy. May swab
lips with a glycerine-based emollient.
(The medication may cause dry mucous
membranes.)
Initiate safety measures to prevent falls.
(The medication may cause drowsiness.)


Monitor electrolyte levels.
Patient Education/Discharge Planning
Advise patient to:
 Record the frequency of stools. Instruct
patient to note if any blood is present.
 Report any abdominal pain or abdominal
distention to the health care provider
immediately
Instruct patient to:
 Report worsening of diarrhea to health
care provider
 Report occurrence of bloody stools to
health care provider
 Increase fluid intake and to drink
electrolyte enriched fluids.
 Advise patient to suck on sour candy or
chew gum to relieve sensations of dry
mouth.
Advise patient to:
 Not drive or operate heavy machinery due
to drowsiness.
 Abstain from the use of alcohol while
using this medication
 Advise patient to keep all laboratory
appointments.
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 Prochlorperazine (Compazine)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Injury, Risk for (fall) related to
dizziness secondary to drug therapy
 Obtain complete health history including
allergies, drug history and possible drug
 Fluid volume, Risk for Imbalance:
interactions
deficit related to ineffective response
to drug therapy
 Assess for presence/history severe
nausea, vomiting
 Nutrition, Risk for Imbalanced: less
 Obtain vital signs
than body requirements related to
nausea and vomiting
 Assess for presence of dehydration,
sodium level, chloride level, potassium
 Knowledge, Deficient, related to drug
level, and temperature.
therapy and side effects
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of need for drug therapy and will comply with all instruction
given
 Remain free of drug side effects including rash, blurred vision, jaundice, tremor and
changes in vision.
 Maintain adequate fluid balance
 Maintain adequate nutrition
 Remain free of physical injury
Implementation





Interventions and (Rationales)
Monitor neurological status (Seizure
threshold is decreased. May need to
increase seizure medication.)
Monitor intake and output (to evaluate
drug effectiveness),
Monitor elimination pattern. (Medication
may cause urinary retention.)
Institute safety procedures to prevent
patient falls or injuries.
Monitor changes in skin integrity.
(Medication may cause gray–blue
discoloration of skin.)
Patient Education/Discharge Planning
 Advise patient with a seizure disorder
that there is an increased risk for seizures
with this medication.
Advise patient:
 To report continue nausea and vomiting
 That medication may cause urine to
appear reddish brown
 Instruct patient to report difficult
urination to health care provider.
 Advise patient to avoid driving or
operating heavy machinery due to
sedating effects of medication.
Advise patient:
 To protect skin from direct sunlight and
to use sunscreen
 That medication may cause sun exposed
skin to turn gray blue
Evaluation of Outcome Criteria
Evaluste the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Sibutramine (Meridia)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Nutrition, Risk for Imbalanced: more
than body requirements related to
 Obtain complete health history including
allergies, drug history and possible drug
ineffective response to drug therapy
interactions
 Tissue perfusion, Risk for Ineffective
related to adverse effects of drug
 Assess for presence/history obesity, desire to
lose weight
therapy
 Assess weight, blood pressure, pulse, EKG,
 Gas exchange, Risk for Impaired
liver function and kidney function
related to respiratory difficulty
secondary to adverse effects of drug
therapy
 Injury, Risk for (anaphylaxis) related to
adverse effects of drug therapy
 Knowledge, Deficient related to drug
action and side effects
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of adverse reaction to drug including severe headache, fever, muscle aches,
tachycardia, rash, nausea, vomiting, profuse sweating, tremor, irritability and respiratory
difficulty.
 Demonstrate weight loss within expected range
 Maintain adequate tissue perfusion
 Demonstrate knowledge of drug action and side effects
Implementation


Interventions and (Rationales)
Obtain medication history for concurrent
use of SSRIs. (Medication may cause
serotonin syndrome.)
Monitor weight pattern (to evaluate
effectiveness of drug therapy).

Monitor intake and output (to evaluate
compliance with treatment regimen.)

Monitor liver function, bilirubin, alkaline
phosphatase and lipid profile. (There is an
increased risk of liver dysfunction.)
Patient Education/Discharge Planning
 Instruct patient to immediately report the
development of any rash, fever or
difficulty breathing.
Advise patient to:
 Keep weight record
 Report weight increase to health care
provider
Encourage patient to:
 Remain compliant with prescribed
dietary and lifestyle modifications
 Take medication as prescribed by the
health care provider
 Advise patient to keep all laboratory
appointments.

Monitor patients with narrow angle
 Advise patient to report any vision
glaucoma for increased intraocular
changes to the health care provider
pressure (Medication may worsen
immediately.
condition.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).