Nursing Process Focus:
Patients Receiving Chlorothiazide (Diuril)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Comfort, impaired,
nausea/vomiting, related to effects
 Obtain complete health history
including allergies, drug history and
of chlorothiazide
possible drug interactions
 Falls, risk for, related to orthostatic
hypotension secondary to
 Assess for presence/history of serious
kidney dysfunction, hypokalemia,
medication
decreased liver function, diabetges
 Knowledge, deficient, related to
mellitus, decreased liver function
effects of thiazide diuretics
 Lab values for CBC, BUN, creatinine,
 Fluid volume, deficient, related to
electrolytes, uric acid, blood glucose
excessive dose of chlorothiazide
 Obtain vital signs
 Noncompliance, recommended
medication regime, related to
 Assess for peripheral edema
unpleasant side effects,
 Obtain body weight
misunderstanding of need to take
medication exactly as ordered
Planning: Patient Goals and Expected Outcomes
Patient will

Take medication as ordered, without increasing or decreasing unless
recommended by health care provider
 Experience no side effects or adverse reactions
 Experience increased urinary output, decreased blood pressure
 Demonstrate knowledge of mechanisms of action of chlorothiazide
 Demonstrate knowledge of eating potassium-rich diet or of taking potassium
supplement, but not both unless specifically recommended by health care provider
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Obtain history of drug allergies.
 Instruct patient to report all allergies to
(Chlorothiazide is a sulfonamide, so
the health care provider.
it patient is sensitive to one sulfa
drug, he/she will not be able to take
it.)
 Monitor renal function.
 Instruct patient to monitor intake and
(Chlorothiazide cannot be given to
output and report changes in urine
patient with severe renal
amount to health care provider.
dysfunction or anuria.)
Instruct patient to:
 Monitor potassium levels.
(Chlorothiazide decreases
 Recognize signs and symptoms of
potassium levels, patient must be
hypokalemia, including leg cramps,
monitored closely for normal levels
nausea, vomiting, cardiac dysrhytmias.
throughout therapy.)
 Report symptoms to health care
provider


Add potassium rich foods to diet such
as citrus fruit and melons
Instruct patient to:
 Monitor blood glucose closely.
 Report consistent hyperglycemia to the
health care provider
Monitor blood sugar levels if
patient is diabetic or pre-diabetic.
(Chlorothiazide may cause
hyperglycemia and glycosuria.
Patient may need dosage
adjustments of hypoglycemic
drugs.)
 Monitor for gout. (Patient with gout  Instruct patient to report worsening of
may experience hyperuricemia
symptoms of gout to the health care
without symptoms, secondary to
provider.
chlorothiazide’s interference with
uric acid excretion.)
 Monitor intake and output for
 Instruct patient to report either oliguria
equality between intake and output
or extreme diuresis immediately.
in a 24-hour period. (Excessive
diuresis, or oliguria, can lead to
electrolyte imbalances.)
Teach patient/caregivers:
 Provide safe environment.
(Chlorothiazide may cause
 Measures to decrease falls if
Orthostatic hypotension placing
orthostatic hypotension occurs
patient at risk for falls.)
 To change position slowly, rise slowly
Evaluation of Outcome Criteria
Evaluatge the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving SPIRONOLACTONE (Aldactone)
Assessment
Prior to administration:
 Obtain complete health history
including allergies, drug history and
possible drug interactions.
 Vital signs
 Serum, electrolytes, creatinine, CBC,
ABGs, BUN)
 Obtain body weight
 Assess for presence/history of
decreased liver or kidney function
Potential Nursing Diagnoses
 Body image, disturbed
(gynecomastia in males, hirsutism in
females) related to anti-estrogen
effects of spironolactone
 Diarrhea, related to side effects of
medication
 Fluid volume, deficient, risk for,
related to excessive doses of
spironolactone
 Knowledge, deficient, related to no
effects of medication
Planning: Patient Goals and Expected Outcomes
The patient will:




Experience increased diuresis.
Exhibit decreased or absent edema or crackles.
Demonstrate blood pressure and potassium values within normal limits
Demonstrate knowledge of mechanisms of action of spironolactone, side effects
and adverse reactions
 Mainatain absence of diarrhea
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Monitor renal function.
 Instruct patient to report changes in
(Spironolactone cannot be used if
urinary output to the health care
anuria, worsening decreased kidney
provider.
function, or acute renal insufficiency
is present. Use cautiously if BUN is
40 or above.)
 Monitor serum potassium levels
 Advise patient regarding signs and
results for impending hypokalemia or
symptoms of hypokalemia or
hyperkalemia. (The patient is at risk
hyperkalemia including leg cramps,
for cardiac dysrhytmias.)
nausea, vomiting, irregular heart
rhythm.

Monitor daily weight and intake and
output (to determine fluid loss).
Instruct patient/caregivers to:
 Weigh daily or on schedule
recommended by health care provider,
and record, and report changes of >3
pounds if doing daily weights, or >5
pounds if once weekly weights

Weigh at same time every day, same
scale, and in same amount of clothing,
in order to get most accurate weight
possible
 Monitor for symptoms of metabolic
 Instruct patient caregivers to monitor
acidosis.
for drowsiness, restlessness.
Instruct patient to:
 Monitor diet for food high in
potassium (may lead to
 Avoid foods with high potassium
hyperkalemia).
content (bananas, oranges, orange juice,
dried apricots, Sanka, etc.)
 Avoid use of potassium-based salt
substitutes, and to get permission of
health care provider before using any
salt substitute
 Monitor for side effects/adverse
 Advise patient/caregiver to be aware of
reactions.
and report: nausea/vomiting, diarrhea,
burning of tongue, lethargy, confusion,
headache, dizziness, drowsiness, gout,
rash, or urticaria
 Monitor for sexual changes. (Patient
 Instruct patient/caregiver to report
may experience decreased libido,
changes to health care provider
hirsutism in females, gynecomastia
immediately, but not to abruptly
and/or impotence in males, irregular
discontinue taking spironolactone
menses or possibly amenorrhea, postunless recommended by health care
menopausal bleeding, or deepening of
provider.
the voice in females.)

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 SODIUM BICARBONATE
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Gas exchange, impaired, related to
acidosis or alkalosis
 Obtain complete health history including
allergies, drug history and possible drug
 Fluid volume excess, related to
interactions
bicarbonate
 Assess for presence/history of metabolic
 Knowledge, deficient, related to proper
acidosis or alkalosis, cardiovascular disease,
use of sodium bicarbonate
decreased renal function, peptic ulcer disease
 Obtain vital signs
 Monitor ABGs
Planning: Patient goals and Expected Outcomes
Patient will:
 Demonstrate reversal of symptoms of acidosis or alkalosis
 Demonstrate pH between 3.5-5.3, and sodium level between 135-145
 Demonstrate understanding of proper uses/application of sodium bicarbonate products
Implementation
Interventions and (Rationales)
Patient Teaching/Discharge Planning
 Monitor for alkalosis. (Indicates drug
 Advise patient and caregiver regarding
effectiveness.)
symptoms of alkalosis: irritability,
confusion, cyanosis, slow respirations,
irregular pulse, muscle twitching.
 Monitor for metabolic acidosis. (Sodium
 Advise patient and caregiver regarding
bicarbonate is used to neutralize acidosis.)
symptoms of acidosis: sleepiness, coma,
disorientation, dizziness, headache,
seizures, hypoventilation.
 Monitor respirations, pulse, lung sounds,
 Advise patient that frequent vital signs
fluid balance, pH, ABGs.
checks and lab studies will be performed.
 Monitor for decreased renal function.
 Advise patient that intake and output
(Drug will not be excreted, leading to
balance, pH of urine, daily weight will be
metabolic alkalosis.)
done.
 Monitor for hyponatremia: elevated blood  Advise patient regarding symptoms of
pressure, cold, clammy skin, anorexia,
hyponatremia and to notify health care
vomiting, diarrhea, abdominal cramps
provider/health care provider if he/she
lethargy, fatigue, confusion, headache,
notes any of symptoms listed in previous
seizures, coma, tremors
column
 Monitor for hypokalemia.
 Advise patient regarding symptoms of
hypokalemia including muscle cramps,
nausea, irregular heart rhythm and to report
symptoms 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 POTASSIUM CHLORIDE
Assessment
Potential Nursing Diagnosis
Prior to administration:
 Falls, risk for, R/T adverse reactions to
 Obtain complete health history including
medication
allergies, drug history and possible drug
 Knowledge, deficient, proper use of
interactions.
medication, R/T no previous exposure
 Assess for presence/history of severe renal
 Skin integrity, impaired, risk for, R/T
disease, hypokalemia, hyperkalemia,
extravasation at IV site
dehydration, acidosis or alkalosis, cardiac
 Therapeutic regimen management,
dysrhythmias
ineffective, R/T lack of understanding
regarding other medication/food use
 Urinary elimination, impaired,
decreased urinary output, R/T
medication use
PLANNING: PATIENT GOALS and EXPECTED OUTCOMES
Patient will:
 Remain free of physical injury
 Demonstrate knowledge of drug therapy, side effects, and adverse reactions
 Maintain intact skin integrity
 Demonstrate understanding of possible drug interactions
 Maintain urinary elimination within normal range
Implementation
Interventions and (Rationales)
Patient Teaching/Discharge Planning
 Monitor serum potassium levels
 Instruct patient to be aware of symptoms
(indicates effectiveness of therapy)
of hyperkalemia: nausea, abdominal
cramping, oliguria, weakness, changes in
heart rate, numbness or tingling of arms
or legs
 Monitor kidney function. (Damaged
 Advise patient and caregiver regarding
kidneys are unable to excrete normal
the importance of kidney function tests
amounts of potassium, leading to
and of complete disclosure of past
hyperkalemia.)
medical history.
Instruct patient to:
 Monitor diet for excessive foods
containing potassium. (There is a risk for
 Avoid use of salt substitute without
hyperkalemia resulting in cardiac
approval of health care provider
dysrhythmias. Patient receiving
 Avoid increasing potassium rich foods
potassium supplements should avoid use
while taking a potassium supplement,
of salt substitute since most use
including bananas, oranges, orange juice,
potassium in place of sodium.)
broccoli, carrots, brussel sprouts, etc.
 Monitor for overdose. (Patient is at risk
 Advise patient and caregiver that
for cardiac dysrhythmias.)
frequent blood studies will be done so
early hyperkalemia will be identified.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).