Nursing Process Focus: Patients Receiving LINDANE (Kwell)
ASSESSMENT
POTENTIAL NURSING DIAGNOSES
Prior to administration:
■
Obtain
complete
■
health
history
including
allergies, drug history, and possible drug
Deficient Knowledge, related to no previous
contact with lice or mites or treatment
■
interactions.
Treatment Regimen Noncompliance, related to
knowledge deficit, embarrassment
■
Assess vital signs.
■
Assess skin for presence of lice and/or mite
■
Risk for Impaired Skin Integrity, related to
lesions and itching
infestation, skin lesions, raw or inflamed skin,
and open cuts.
■
Obtain history of seizure disorders.
■
Obtain patient’s age.
■
Assess pregnancy and lactation status.
■
Obtain social history of close contacts, including
household members and sexual partners.
PLANNING: PATIENT GOALS AND EXPECTED OUTCOMES
■
Patient and significant others will be free of lice or mites and experience no reinfestation.
■
Patient will express an understanding of how lice and mites are spread, proper administration of
lindane, necessary household hygiene, and the need to notify household members, sexual partners,
other close contacts such as classmates of infestation.
■
Skin will be intact and free of secondary infection and/or irritation.
IMPLEMENTATION
Interventions and (Rationales)
■
Patient Teaching/Discharge Planning
Monitor for presence of lice or mites.
Instruct patient and caregiver to:
(This determines the effectiveness of drug
■
therapy.)
Examine for nits on hair shafts; lice on skin or
clothes; inner thigh areas; seams of clothes that
come in contact with axilla, neckline, or beltline
■
Examine for mites between the fingers, on the
extremities, axillary and gluteal folds, around the
trunk, and in the pubic area
■
Apply lindane properly. (Proper application is
Instruct patient and caregiver:
critical to elimination of infestation.)
■
To wear gloves during application, especially if
applying lindane to more than one person, or if
pregnant
■
That all skin lotions, creams, and oil-based hair
products should be removed completely by
scrubbing the whole body well with soap and
water, and drying the skin prior to application
■
To apply lindane to clean and dry affected body
area as directed, using no more than 2 oz per
application
■
That
eyelashes
can
be
treated
with
the
application of petroleum jelly twice a day for 8
days followed by combing to remove nits
■
To use fine-tooth comb to comb affected hair
following lindane application to the hair and
scalp to treat all household members and sexual
contacts simultaneously
■
To recheck affected hair or skin daily for 1 week
after treatment
■
Inform patient and caregivers about proper care
Instruct patient and caregiver to:
of clothing and equipment. (Contaminated
■
articles can cause reinfestation.)
Wash all bedding and clothing in hot water, and
to dry-clean all nonwashable items which came
in close contact with patient
■
Clean combs and brushes with lindane shampoo
and rinse thoroughly
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 BENZOCAINE (Solarcaine)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Comfort, impaired, related to presence
 Obtain complete health history including
of sunburn, burns, toothache, ear
allergies, drug history and possible drug
infections, etc.
interactions.

Knowledge, deficient, related to lack of
 Assess for presence/history of sunburn,
proper education regarding health
minor burns, serious burns, mild pruritus
practices necessary to prevent sunburn,
burns, etc. and lack of previous contact
with benzocaine
 Noncompliance, overuserelated to
reluctance to contact health care
provider if symptoms continue past
recommended maximum usage time
Planning: Patient Goals and Expected Outcomes
Patient will:
 Experience improvement in symptoms without complications
 Demonstrate proper use of benzocaine
 Demonstrate necessity to contact health care provider if symptoms do not improve, or
worsen, by the time maximum recommended usage is reached
 Demonstrate knowledge of measures to take to prevent sunburn, burns, etc. from occurring
in future
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Teach patient to:
 Monitor for secondary infection. (Drug
should not be used if infection is present
 Examine affected areas prior to each
in area of sunburn or insect bites.)
application of benzocaine
 Discontinue use of benzocaine if
redness, swelling, pain appears or
worsens
 Monitor status of burns. (Drug should not Advise patient that :
be used if serious burns are present.)
 Benzocaine cannot be used on burns
deeper than one skin layer or if skin is
broken and/or weeping
 If pain is not present, it can be an indicator
of the seriousness of burn, since nerve
endings may have been damaged
Advise patient and caregiver:
 Monitor for perforated tympanic
membrane or discharge from ear(s).
 to use caution whenever applying to the
external ear to prevent its getting into the
inner ear
 not to use without health care provider
approval if patient has pain in ear,
decreased hearing, discharge

Monitor for proper use. (Since Instruct patient:
benzocaine is OTC medication, patient
 To use only on intact skin, to avoid eyes,
may not understand proper use or
areas of local sepsis
precautions.)
 That benzocaine is to be used no more
than 7 days
 To discontinue benzocaine if symptoms
of hypersensitivity occur (redness, pain,
rash, heat) and to contact health care
provider if pain lasts longer than 48
hours
 To do not chew gum or eat until
anesthetic effects of benzocaine used for
toothache relief have worn off
 In infant proper use of benzocaine for
relief of teething
Instruct
patient to discontinue use of
 Monitor for worsening of condition.
benzocaine and contact health care provider if
increased pain, pruritus, heat, or other
symptoms occur.
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 ISOTRETINOIN (Accutane)
ASSESSMENT
POTENTIAL NURSING DIAGNOSES
Prior to administration:
■
■
Disturbed Body Image, related to presence of
Obtain complete health history including
acne and possible worsening of symptoms after
allergies, drug history, and possible drug
treatment begins
interactions.
■
Decisional Conflict, related to desire for
■
Obtain pregnancy and lactation status.
pregnancy, and necessity of preventing
■
Assess for history of psychiatric disorders.
pregnancy during therapy with isotretinoin
■
Assess vital signs to obtain baseline information.
■
Noncompliance, related to length of treatment
time, failure to use effective contraception
■
Impaired Skin Integrity, related to inflammation,
redness, scaling, secondary to treatment
PLANNING: PATIENT GOALS AND EXPECTED OUTCOMES
The patient will:
■
Experience decreased acne, without side effects or adverse reactions
■
Demonstrate acceptance of body image
■
Demonstrate an understanding of the drug’s action by accurately describing drug side effects and
precautions
IMPLEMENTATION
Interventions and (Rationales)
■
Monitor lab studies during treatment, including
Patient Education/Discharge Planning
■
blood glucose.
Instruct patient on importance of lab studies prior
to therapy and periodically during therapy and
doing home blood glucose monitoring if diabetic.
■
Discuss potential adverse reactions to drug
Instruct patient to
therapy. (Understanding of drug effects is
■
important for compliance.)
Use two forms of reliable birth control for 1
month before beginning treatment, during
treatment, and for 1 month following completion
of treatment
■
Not donate blood during treatment and for a
minimum of 4 weeks after completion of
treatment; isotretinoin in donated blood could
cause fetal damage if given to a pregnant woman
■
Talk with pediatrician about alternative methods
of feeding if breastfeeding
■
Monitor for cardiovascular problems. (Use
■
Avoid use of vitamin A products
■
Discuss with patient importance of complete
isotretinoin with caution in patients with heart
disclosure regarding medical history and
block, especially if patient is also taking a beta-
medications.
blocker.)
■
Monitor emotional health. (Patient may become
Instruct patient:
depressed secondary to acne itself, length of
■
treatment, possibility of worsening symptoms at
beginning of treatment, changed body image, or
Regarding signs and symptoms of depression and
to report
■
drug itself.)
To report signs of depression or any feelings of
suicide ideation immediately and discontinue
isotretinoin
■
■
Monitor CBC, blood lipid levels, glucose levels,
■
Teach patient importance of a complete workup
liver function tests, eye exam, GI status,
prior to starting isotretinoin therapy and
urinalysis.
periodically during course of treatment.
Monitor for vision changes. (Corneal opacities
Instruct patient:
and/or cataracts may develop as result of
■
isotretinoin use. Dryness of eyes during
To report any decreased vision and discontinue
use of isotretinoin
treatment is common. Night vision may be
■
To avoid driving at night if possible
diminished during treatment.)
■
Use of artificial tears to relieve dry eyes
■
That use of contact lenses may need to be
discontinued during therapy
■
Monitor alcohol use. (Alcohol use with
Advise patient to:
isotretinoin leads to increased triglyceride
■
levels.)
Eliminate or greatly reduce alcohol use,
including alcohol-containing preparations such
as mouthwashes or OTC medications
■
■
Read labels for alcohol content
Monitor skin problems. (This will determine the
Advise patient:
effectiveness of drug therapy.)
■
That acne may worsen during beginning of
treatment
■
To monitor skin for improvement in 4 to 8
weeks; if no improvement is noted, patient
should contact primary healthcare provider
■
Monitor for side effects: headache (especially if
accompanied by nausea and vomiting), fatigue,
■
Instruct patient regarding possible side effects
and to report immediately if any occur
depression, lethargy, severe diarrhea, rectal
bleeding, abdominal pain, dry mouth, hematuria,
proteinuria, liver dysfunction (jaundice, pruritus,
dark urine. Report immediately
EVALUATION OF OUTCOME CRITERIA
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have
been met (see “Planning”).