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
contraception
Planning: Patient Goals and Expected Outcomes
Patient will:

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
Demonstrate compliance with medication regimen
Avoid pregnancy
Remain free of side effects
Demonstrate knowledge of drug therapy and potential side effects
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Teach patient:
 Monitor for pregnancy. (Medication
must not be administered to woman
 That she must have had negative pregnancy
who is pregnant. Medication is
test within 2 weeks prior to beginning
teratogenic.)
medication
 To immediately have pregnancy test if
pregnancy is suspected during therapy
Teach patient to:
 Monitor for breast or other estrogendependent tumors. (Estrogen in
 Give full medical and family medical history
medication may cause tumor growth or
prior to beginning therapy
proliferation.)
 Report to health care provider immediately if
1st degree relative is diagnosed with any
estrogen-dependent tumor
 Observe for thrombophlebitis or other
 Advise patient of signs of possible
thromboembolic disease. (Estrogenthromboembolic event, and to immediately
containing medications predispose a
report: pain in calves, limited movement in
woman to thromboembolism.)
legs, dyspnea, sudden severe chest pain,
anxiety, fear.

Monitor for cardiac disorders.
(Medication will lead to worsening of
cardiac problems.)

Monitor for cerebrovascular disorders.
(Medication increases risk for
thrombotic disorders, one of leading
causes of CVA.)
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Obtain 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.)
Monitor mental status. (Side effects
such as weight gain may cause
depression in some women.)
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 hyperglycemia; adjustments in dose of
hypoglycemic medications may be
necessary.)
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 of signs of possible cardiac
problems which must be immediately
reported: chest pain, dyspnea, edema,
tachycardia or bradycardia, palpitations.
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
taken
Advise patient to:
 Stop smoking prior to beginning treatment
with oral contraceptives
 Attend smoking cessation groups.


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.
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.
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

Advise patient to:
Monitor whether patient understands
how/when to take medication. (Only
 Use barrier contraceptive during 1st week of
with thorough understanding will she
initial cycle and for 7 days after 2 consecutive
be able to take medication correctly and
missed doses
avoid adverse reactions, or be aware of  Discontinue medication and notify health care
physical changes that could be
provider if bleeding resembling menstrual
secondary to the medication, and take
cycle occurs mid-cycle
measures to prevent permanent, serious  Be aware of fluid retention (teach to weigh
harm.)
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 intervals
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 Conjugated Estgrogens (Premarin) and Conjugated Estrogens with
Medroxyprogesterone (Prempro)
ASSESSMENT
POTENTIAL NURSING DIAGNOSES
Prior to administration:
 Body image, disturbed, related to side
 Obtain complete health history including
effects of medication
allergies, drug history and possible drug
 Comfort, impaired, related to effects of
intgeractions
medication
 Assess for presence/history of breast
 Fluid volume, excess, related to edema
cancer, estrogen dependent cancer,
secondary to medication
abnormal genital bleeding,
 Noncompliance, related to unpleasant side
thromboembolic disorders, cardiovascular
effects, desire for pregnancy, lack of
disorders, smoking history, pregnancy
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 medication
PLANNING: 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 development
Implementation
Interventions and (Rationales)
Patient Teaching/Discharge Planning
 Obtain history of cancer in patient or close  Advise patient of importance of complete
relative. (Estrogen-dependent cancer
physical exam prior to beginning therapy
combination of medication and estrogenwith conjugated estrogen.
dependent tumors, either currently or
history of, put patient at much higher risk
for developing cancer.)
Instruct patient to
 Monitor for signs of pregnancy. (Can
cause serious fetal harm.)
 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
pregnant
 Monitor for current or past history of
 Advise patient of importance of complete
thromboembolism. (Estrogen use
disclosure of past medical history.
increases chance of thromboembolism
occurring.)
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Monitor for undiagnosed abnormal uterine
bleeding. (Can increase bleeding, tumor
size, if undiagnosed tumor present.)
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.)
Evaluate 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.)
Monitor for vision changes. (Medication
may cause worsened myopia or
astigmatism, intolerance of contact
lenses.)
Obtain smoking history. (Smoking
increases risk of cardiovascular disease,
especially when in combination with
estrogens.)
Monitor for diabetes mellitus. (Estrogens
may alter blood glucose levels.)

Monitor for seizure disorder. (Estrogeninduced fluid retention may increase
incidence of seizures.)

Observe for side effects. Side effects are
dose dependent, and include: weight gain,
edema, nausea/vomiting, abdominal
cramps and bloating, acute pancreatitis,

Instruct patient to have complete physical
exam prior to beginning therapy.
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 occur
 Advise patient of importance of complete
physical exam prior to treatment and
periodically during treatment.
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 occurs
Instruct patient to:
 Quit smoking
 Attend smoking cessation programs

Advise diabetic patient to monitor blood
glucose frequently and report if any
consistent changes.
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
occurring
 Advise patient of common side effects and
to be alert to occurrence of them.

appetite changes, skin eruptions, mental
depression, decreased libido, headache,
fatigue, nervousness.
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.
Instruct patient:
 Evaluate patient’s understanding and
proper self-administration. (To ensure
 Regarding dose, form and frequency of
patient safety)
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
estrogens
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 Medroxyprogesterone (Provera)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Health maintenance, ineffective, related to
 Obtain complete health history including
lack of knowledge or understanding of
allergies, drug history and possible drug
positive health practices, such as smoking
interactions.
cessation
Assess for presence/history of:

Nausea, related to side effects of
 Pregnancy
medication
 Dysfunctional uterine bleeding
Nutrition, imbalanced, less than or more
 Metastatic endometrial or renal cancer
than body requirements related to
 Endometrial hyperplasia
imbalance in hormone make-up
 Thrombophlebitis or thromboembolic
 Sexual dysfunction, relate to hormonal
disease
imbalance
 Breast cancer
 Sleep pattern disturbed, insomnia, related
 Decreased liver or kidney function
to effects of medication
 Depression
 Therapeutic regimen management,
 Epilepsy
ineffective, related to knowledge deficit or
 Asthma
planned failure of therapy
 Migraine headache
 Cardiac disorders
PLANNING: 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 changes
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Monitor for pregnancy. (Medication must
 Instruct patient that she must have
not be administered to woman who is
negative pregnancy test within 2 weeks
pregnant; will cause serious fetal
prior to beginning medication.
damage.)
Advise patient:
 Monitor for seizure disorder. (Fluid
retention secondary to medication may
 Of importance of consulting health care
increase seizure activity. Use with
provider who ordered anticonvulsants
caution in women with seizure disorders.)
before beginning this medication
 Regarding life-style changes that may
decrease chances of triggering seizure
activity

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
 Advise patient and caregivers regarding
in women with history of depression.
symptoms of depression to note and
Medication may cause nervousness,
report: changes in eating and sleeping
insomnia, worsening of depression.)
habits, disinterest in every-day activities,
failure to perform ADLs, etc.
Instruct
patient:
 Evaluate patient’s knowledge level.
(Informed patient will comply more fully
 How and when to take medication, and
with
importance of taking exactly as ordered if
being used for contraception
 administration regime, and be more
aware of and alert to adverse reactions.)
 Proper self-administration if being taken
as cancer therapy
 Regarding symptoms of hypercalcemia
Instruct patient to:
 Monitor for side effects: amenorrhea,
nausea, jaundice, dizziness, headache,
 Monitor for side effects and to report to
signs of pulmonary embolism (sudden
health care provider if they occur
severe chest pain and dyspnea), edema,
 Monitor for edema or weight gain by
weight gain. Report immediately
weighing self weekly and recording;
noting if rings or shoes become tight
Instruct
patient:
 Observe foreskin changes caused by
reactions to medication.
 To monitor for pruritis, urticaria, acne,
rash, hirsutism, alopecia
 That these changes are temporary and will
improve upon discontinuation of this
medication
Evaluation of Outcome Criteria
Evaluate effectiveness of drug therapy by confirming patient goals and expected outcomes have
been met (see “Planning”).
Monitor for hypercalcemia. (Medication
may cause increased serum calcium
levels, especially if in conjunction with a
low daily fluid intake.)
Nursing Process Focus:
Patients Receiving Oxytocin
Assessment
Potential Nursing Diagnosis
Prior to administration:
 Comfort, Impaired related to strong uterine
contractions
 Obtain complete health history
including complete past and present
 Excessive fluid volume
gynecological and obstetric history
 Injury, Risk for to fetus related to effect of
 Obtain drug history to determine
drug on uterine contractions
possible drug interactions and allergies
 Obtain vital signs
 Asses fetal monitoring
Planning: 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 drug’s 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.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Administer IV medication through
 Inform patient regarding the need for
infusion device (To maintain accurate
equipment.
dosing)
 Monitor fetal heart rate. (Increase in force  Instruct patient about the purpose and
and frequency of uterine contractions may
importance of fetal monitoring.
cause fetal distress.)
 Monitor maternal status including BP,
 Instruct patient about the importance of
pulse, and frequency, duration and
monitoring maternal status.
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)
 Monitor fluid balance. (Prolonged IV
 Instruct patient to report symptoms of water
infusion may cause water intoxication.)
intoxication including drowsiness,
listlessness, headache, confusion, anuria, or
weight gain.
Instruct patient:
 Monitor for post partum/post abortion
hemorrhage.
 About the importance of being monitored
frequently after delivery or after abortion
 To report severe vaginal bleeding or
increase in lochia
Evaluation 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
Potential Nursing Diagnosis
Prior to administration:
 Body image, disturbed, related to lack of
 Obtain complete health history including
normal sexual development, impotence,
allergies, drug history and possible drug
decreased sperm count, growth
interactions.
retardation, gynecomastia,
 Assess for presence/history of
virilism in females
hypogonadism, secondary sex
 Coping, ineffective, related to delayed
characteristics, increased or decreased
sexual development and inability to
libido, low sperm count, impotence
accept this
 Monitor history of cardiovascular disease
 Family processes, interrupted, related to
male’s 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 androgen
Planning: 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 function
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to:
 Monitor for prostatic or male breast
cancer. (Testosterone will worsen either
 Have complete medical exam including
condition.)
PSA tests prior to taking testosterone and
periodically during therapy
 Note and report any symptoms of altered
urinary function: retention, hesitancy,
nocturia, hesitancy, frequency, dribbling
 Monitor for serious renal disease. (Edema Instruct patient to:
caused by testosterone and added stress
 Have renal function tests, BUN, creatinine
placed on the kidneys.)
performed prior to testosterone therapy and
periodically during therapy
 Report immediately any symptoms of
kidney dysfunction: decreased urination,
edema, uremic frost, confusion, etc.
Instruct patient to:
 Monitor for decreased cardiac function.
(Edema caused by testosterone stresses
 Have cardiac function tests performed prior
the heart.)
to and periodically during therapy
 Immediately report symptoms of decreased
cardiac function: general weakness, fatigue,
dyspnea, and edema
Instruct
patient:
 Monitor serum cholesterol levels.
(Elevated cholesterol levels secondary to
 To have cholesterol levels measured prior to
testosterone administration may increase
and periodically during therapy
patient’s risk of cardiovascular disease.)
 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 Instruct patient:
or lactation. (Testosterone crosses into
 To have negative pregnancy test within 2
breast milk and may cause damage to
weeks before initiating testosterone therapy
infant, including masculinization of
and monthly during therapy
female infant.)
 Regarding the importance of reliable birth
control during testosterone therapy
Instruct patient:
 Monitor for hypercalcemia.
(Hypercalcemia in patient with metastatic
 To have lab studies performed prior to
breast cancer usually indicates bone
and during therapy
metastasis.)
 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, psychoses
 Evaluate bone growth in children and
 Advise patient and caregivers that bone age
adolescents. (Premature epiphyseal
determinations should be done every 6
closing may occur, leading to growth
months.
retardation.)
Advise patient:
 Monitor fluid intake. (Increased fluids
will increase urine production and
 To consume 3,000-4,000cc fluid daily
decrease chance of stone formation.)
 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.
Instruct patient to:
 Monitor for diabetes mellitus.
(Testosterone therapy may change glucose  Monitor blood sugar daily and notify health
tolerance.)
care provider if changes occur
 Make needed adjustments in hypoglycemic
medications and diet
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 Sildenafil (Viagra)
Assessment
Potential Nursing Diagnosis
Prior to administration:
 Body image, Disturbed related to impaired
sexual function
 Obtain complete health history including
hematologic disorders, cardiac, kidney
 Sexual dysfunction related to known or
or liver disease, and anatomic
unknown cause
deformities
 Sensory perception, disturbed, visual related to
 Obtain drug history, specifically organic
disease process.
nitrates and nitroglycerin, to determine
possible drug interactions and allergies
Planning: Patient Goals and Expected Outcomes
Patient will:
 Report more positive body image during drug therapy
 Report normal sexual function
 Demonstrate understanding of the drug’s action by accurately describing side effects and
precautions, and importance of follow-up care
Implementation
Interventions and (Rationales)
Patient Teaching/Discharge Planning
 Monitor cardiovascular status. (Patient Instruct patient and/or caregiver to:
who has 1st attack of angina during
 Carry identification stating he is taking
time he is taking sildenafil should not
Sildenafil, so he will not be given nitrates
receive any nitrate products.
 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 lifestyle
Instruct patient and/or caregiver to:
 Monitor sexual response to include:
*Frequency, firmness, maintenance of
 Keep diary R/T use of sildenafil, sexual
erections;
response, any cardiovascular symptoms that
*Frequency of orgasms
may occur
*Frequency, satisfaction and enjoyment of  Report any changes to health care provider
sexual activity;
 Seek emergency care if erection lasts longer
*Satisfaction with sexual relationship
that 4 hours.
Instruct patient and/or caregiver to:
 Monitor diet. (High fat meals can
delay absorption of sildenafil and
 Avoid administration of Sildenafil with meals,
delay onset of action by 1 hour.
especially high-fat meals
Taking sildenafil with grapefruit juice  Avoid grapefruit juice when administering
may lead to increased serum sildenafil
Sildenafil
levels, leading to adverse effects.)

Instruct patient and/or caregiver that:
 Sildenafil should not be taken more than once
in a 24 hour period
 Optimum time to take Sildenafil is 1 hour
prior to sexual activity, but that it can be taken
for up to 4 hours prior
 Sildenafil will not produce erection unless he
is sexually stimulated
 This medication should not to share
medication with anyone else
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Monitor patient knowledge and
understanding.