Nursing Process Focus:
Patients Receiving Phenelzine (Nardil)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Sorrow, Chronic related to
depressive state.
 Obtain complete medical history
including allergies, neurological , cardiac,  Thought Processes, Disturbed related to
renal, biliary, and mental disorders
effects of drug therapy
including blood studies: CBC, platelets
 Adjustment, Impaired related to inadequate
and liver enzymes,.
drug effectiveness.
 Obtain patient’s drug history to determine  Knowledge, Deficient, related to drug
possible drug interactions and allergies
action and side effects.
 Obtain 24 hour dietary history to identify  Suicide, Risk for related to inadequate drug
tyramine containing foods ingested
effectiveness.
recently
 Hopelessness related to emotional state.
 Assess neurological status, including
identification of recent mood and
behavioral patterns
Planning: Patient Goals and Expected Outcomes
The patient will

Report mood elevation and will effectively engage in activities of daily living.

Report an absence of suicidal ideations and improvement in thought processes.

Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct the patient to immediately report:
 Monitor vital signs, especially pulse
and blood pressure. (Phenelzine may
 Any change in sensorium particularly
cause orthostatic hypotension.)
impending syncope.

Avoid abrupt changes in posture; rise
slowly from prolonged periods of
sitting/lying down.

Monitor vital signs (especially blood
pressure) ensuring proper use of home
equipment.
 Consult the health care provider regarding
"reportable" blood pressure readings (e.g.
"lower than 80/50).
Monitor cardiovascular status.
 Instruct patient to immediately report severe
headache, dizziness, paresthesias,
 Observe for hypertensive crisis and
signs of impending stroke or M.I.:
bradycardia, tachycardia, nausea/vomiting,
severe headache, dizziness,
diaphoresis.
paresthesias, bradycardia, tachycardia,
nausea/vomiting, diaphoresis.
Monitor neurological status.
 Instruct patient to report significant changes
in neurological status, such as seizures,
 Observe for changes in LOC and
seizures. Use with caution in epilepsy.
(MAOIs may reduce the seizure
threshold.)
Monitor mental and emotional status.
 Observe for suicidal ideation.
Therapeutic benefits may take 2-6
weeks.
Monitor kidney and liver function.
 Observe for signs of hepatic toxicity.
Monitor laboratory blood work such as
platelets, PT, PTT, and liver enzymes.
 Assess urinary output and edema in
feet/ankles. (Medication is excreted
through the kidneys. Long term use
may lead to renal dysfunction.)
 Monitor CBC, BUN, creatinine, and
urinalysis.
 Ensure patient safety. (Dizziness
caused by postural hypotension
increases the risk of fall injuries.)
 Raise bed rails. Place call bell within
patient's reach.
extreme lethargy, slurred speech,
disorientation or ataxia.
Interview patient regarding suicide potential;
 Obtain a "no-self harm" verbal contract from
the patient.
 Instruct the patient to immediately report
dysphoria or suicidal impulses.
Instruct the patient to:
 Report nausea, vomiting, diarrhea, rash,
jaundice, abdominal pain, tenderness or
distention, or change in color of stool
 Adhere to a regular schedule of laboratory
testing for liver function as ordered by the
health care provider.
 Report changes in urination, flank pain or
pitting edema immediately.


Instruct the patient to:
Call for assistance before getting out of bed
or attempting to ambulate alone.
 Avoid driving or other activities requiring
mental alertness or physical agility until
blood pressure is stabilized and effects of
the medication are known.
 Teach pt to wear/carry identification stating
taking MAOI.
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 Imipramine (Tofranil)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Sorrow, Chronic related to disease process
 Obtain complete medical history
 Thought Processes, Disturbed related to
including allergies, neurological , cardiac
effects of drug
(including recent MI) renal, biliary, and
 Adjustment , Impaired related to
mental disorders including EKG and
inadequate drug therapy
blood studies: CBC, platelets, BUN,
 Knowledge Deficient , related to drug
creatinine, liver enzymes and urinalysis.
action and side effects
 Obtain patient’s drug history to determine  Suicide, Risk for related to inadequate drug
possible drug interactions and allergies
therapy
 Assess neurological status, including
 Urinary retention related to side effects of
seizure activity and identification of
drug
recent mood and behavioral patterns
Planning: Patient Goals and Expected Outcomes
The patient will
 Report mood elevation and will effectively engage in activities of daily living.
 Report an absence of suicidal ideations and improvement in thought processes.
 Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions.
 Maintain normal urinary flow
Implementation
Interventions and (Rationales)
Patient teaching/discharge planning
Instruct the patient to immediately to:
 Monitor vital signs especially pulse,
and blood pressure. (Imipramine may
 Report any change in sensorium
cause orthostatic hypotension.)
particularly impending syncope.
 Avoid abrupt changes in posture; rise
slowly from prolonged periods of
sitting/lying down.
 Monitor vital signs (especially blood
pressure) ensuring proper use of home
equipment.
 Consult the health care provider regarding
"reportable" blood pressure readings (e.g.
"lower than 80/50).
Monitor cardiovascular status.
 Instruct the patient to immediately report
severe headache, dizziness, paresthesias,
 Observe for hypertension and signs of
impending stroke or M.I and heart
bradycardia, chest pain, tachycardia,
failure. Use with caution in cardiac
nausea/vomiting, diaphoresis or other
patients.
distressing symptoms..
Monitor neurological status.
Instruct patient to
 Observe for somnolence and seizures.
 Report significant changes in neurological
(Imipramine causes somnolence related
status, such as seizures, extreme lethargy,
to CNS depression. Use with caution in
slurred speech, disorientation or ataxia.
epilepsy. Imipramine may reduce the
seizure threshold.)
Monitor mental and emotional status.
 Observe for suicidal ideation.
Therapeutic benefits are delayed. Outpatients should have no more than a 7day medication supply.
 Monitor for underlying mental disease
such as schizophrenia or bipolar
disorders. (Imipramine may trigger
manic states.)
 Interview patient regarding suicide
potential;
 Obtain a "no-self harm" verbal
contract.

Monitor renal status
 Monitor urinary output. (May cause
urinary retention due to muscle
relaxation in urinary tract. Imipramine
is excreted through the kidneys.
Impaired kidney function may result in
reduced medication clearance and
increased serum drug levels. Urinary
retention may exacerbate existing
symptoms of prostatic hypertrophy.)
Instruct patient or caregiver to
 Measure and monitor fluid intake and
output.
 Notify the health care provider of the
following: edema, dysuria (hesitancy, pain,
diminished stream), changes in urine
quantity or quality (eg. cloudy, with
sediment)
 Report fever or flank pain that may be
indicative of a urinary tract infection related
to urine retention.
Instruct the patient to
 Exercise, drink adequate amounts of fluid
and add fiber to the diet to promote stool
passage.
 Consult the health care provider regarding a
bulk laxative or stool softener if
constipation becomes a problem.
Instruct the patient to:
 Report nausea, vomiting, diarrhea, rash,
jaundice, epigastric or abdominal pain,
tenderness, or change in color of stool.
 Adhere to laboratory testing regimen for
blood tests and urinalysis as directed.
Have patient
 Report the following: excessive bruising,
fatigue, pallor, shortness of breath, frank
bleeding and/or tarry stools.
 Demonstrate guiac testing on stool for
Monitor gastrointestinal status.
 Observe for abdominal distention.
(Muscarinic blockade reduces tone and
motility of intestinal smooth muscle,
and may cause paralytic ileus.)
Monitor liver function.
 Observe for signs and symptoms of
hepatic compromise. Monitor blood
studies including CBC, differential,
platlets, PT, PTT and liver enzymes.
Monitor hematologic status.
 Observe for signs of bleeding.
(Imipramine may cause blood
dyscrasias. If given in
hyperthyroidism, can cause
Take dose at bedtime to reduce daytime
sedation.
Instruct the patient:
 That it may take 10-14 days before any
improvement is noticed, and about a month
to achieve full therapeutic effect.
 To immediately report dysphoria , sleepwake cycle changes or suicidal impulses.







agranulocytosis.)
Monitor laboratory blood work (see
previous box). Use with warfarin may
increase bleeding time.
Monitor immune/ metabolic status. Use
with caution in patients with diabetes
mellitus and hyperthryroidism.
(Imipramine may either increase or
decrease serum glucose.)
Monitor for adverse drug effects and
overdosage. Observe for
extrapyramidal and anticholinergic
effects. (In overdosage, 12 hours of
anticholinergic activity is followed by
CNS depression. Cardiac dysrthymia
may also occur.)
Do not treat overdosage with
quinidine, procainamide, atropine or
barbiturates. Use of these drugs
potentiate cardiac depression.
Monitor visual acuity. Use with
caution in narrow-angle glaucoma.
(Imipramine may cause an increase in
intraocular pressure. Anticholinergic
effects may produce blurred vision.)
Ensure patient safety. (Dizziness
caused by postural hypotension
increases the risk of fall injuries.).
Raise bed rails. Place call bell within
patient's reach.
occult blood.
Instruct patients with diabetes to:
 Monitor glucose level daily.
 Consult health care provider regarding
reportable serum glucose levels (eg. "less
than 70 and more than 140").
Instruct the patient/caregiver:
 To immediately report involuntary muscle
movement of the face or upper body (e.g.
tongue spasms), fever, anuria, lower
abdominal pain, confusion, anxiety,
hallucinations, psychomotor agitation,
visual changes, excessively dry mouth and
difficulty swallowing.
 That mild dry mouth may be relieved by
(sugar-free) hard candies, chewing gum and
drinking fluids.
 To avoid alcohol containing mouthwashes
which can further dry oral mucous
membranes.
Instruct the patient to
 Report any disturbing visual changes,
headache or eye pain.
 Inform eye care professional of imipramine
therapy.
Instruct the patient to:
 Call for assistance before getting out of bed
or attempting to ambulate alone.
 Avoid driving or other activities requiring
mental alertness or physical agility until
blood pressure is stabilized and effects of
the medication are known
 Instruct the patient/caregiver that the elderly
may be more prone to side effects such as
hypertension and dysrythmias. Children on
imipramine for nocturnal enuresis may
experience mood alterations.
Use cautiously with the elderly or
young. (Diminished kidney and liver
function related to aging can result in
higher serum drug levels, and may
require lower doses. Children, due to
an immature CNS, respond
paradoxically to CNS-active drugs.)
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 FLUOXETINE (Prozac)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Body image disturbed, related to
weight gain
 Obtain complete medical history including
allergies, neurological, psychological,
 Anxiety, related to drug effect
cardiac, renal, and liver disorders(including
 Coping, Ineffective related to
recent history of seizures or suicidal
inadequate drug therapy
ideation) and including blood studies:
 Knowledge Deficient, related to drug
glucose, BUN, creatinine, electrolytes, liver
action and side effects,
function tests
 Suicide, Risk for related to early drug
 Obtain patient’s drug history to determine
therapy
possible drug interactions and allergies
 Powerlessness, related to depressive
state.
Planning: Patient Goals and Expected Outcomes
The patient will
 Report mood elevation and will effectively engage in activities of daily living.
 Report an absence of suicidal ideations and improvement in thought processes.
 Demonstrate a decrease in anxiety (e.g. ritual behaviors).
 Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Inform the patient/caregivers:
 Observe for Serotonin Syndrome (SS), a
medical emergency. (Serotonin Syndrome  That overdosage may result in serotonin
is possible at high doses, and especially
syndrome, which can be life-threatening.
combined with MAOIs.)
 To seek immediate medical attention for
the following: dizziness, headache,
 For suspected SS, stop the drug and
initiate supportive care: monitor all vital
tremor, nausea/vomiting, anxiety,
signs, including EKG.
disorientation, hyperreflexia, diaphoresis
and fever.
Monitor mental and emotional status.
 Observe for suicidal ideation (Therapeutic
benefits may take a month or more for
ideal response).
 Monitor for presence of underlying or
concomitant mental disorders such as
schizophrenia or bipolar disorders.
(Fluoxetine may trigger mania.)
 Interview patient regarding suicide
potential; obtain a "no-self harm" verbal
contract
 Monitor neurological status. Observe for
seizures. Use with caution in epilepsy.
(Fluoxetine decreases the seizure
threshold.)
 Monitor sleep-wake cycle. Observe for
insomnia and/or daytime somnolence.

Instruct the patient:
 That it may take 10-14 days before any
improvement is noticed, and about a
month to achieve full effect.
 To immediately report dysphoria , sleepwake cycle changes or suicidal impulses.

Instruct patient that if seizures occur, stop
the drug and contact the health care
provider immediately.
Instruct the patient with insomnia to:
 Take the drug very early in the morning to
promote normal timing of sleep onset.
 Avoid driving or potentially hazardous
activities until effects of drug are known.
 Take medication at bedtime if daytime
drowsiness persists.
 Advise the patient to inform the health
care provider of the following: nausea,
vomiting, diarrhea, rash, jaundice,
flank/abdominal pain or tenderness,
changes in urinary quantity and quality or
in stool color.
Monitor kidney and liver function by
laboratory tests such as CBC, BUN,
creatinine, PT, PTT, liver enzymes and
urinalysis. (Fluoxitene is slowly
metabolized and excreted, increasing the
risk of organ damage. Impaired organ
function can further increase drug levels.)
Instruct diabetic patients to:
 Monitor metabolic status. Use with
caution in diabetics. (Fluoxitene may
 Monitor glucose level daily and consult
cause hypoglycemia initially, and
health care provider regarding reportable
hyperglycemia with drug withdrawal.
serum glucose levels (eg. "less than 70
Fluoxitene may also cause initial anorexia
and more than 140").
and weight loss, but with prolonged
 Instruct the patient that anorexia and
therapy may result in weight-gain of up to
weight loss will diminish with continued
twenty pounds.)
therapy.
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 Lithium (Eskalith)
NURSING PROCESS FOCUS PATIENTS RECEIVING LITHIUM (ESKALITH)
Assessment
Prior to administration:
 Obtain complete health history including
allergies, drug history, and possible drug
interactions.
 Assess mental and emotional status,
including any recent suicidal ideation.
 Obtain cardiac history (including) EKG and
vital signs; renal, and liver disorders, and
blood studies: glucose, BUN, creatinine,
electrolytes, and liver enzymes.
Potential Nursing Diagnoses
 Risk for Self-Directed Violence related to
delusional thinking
 Disturbed Thought Processes related to
disease process
 Disturbed Sleep Pattern related to manic
excitement
 Sleep Deprivation (in mania) related to
manic excitement
 Risk for Fluid Volume Imbalance related
side effect of medication
 Impaired Social Interaction related to
egocentric behavior
Planning: Patient Goals and Expected Outcomes
The patient will:
●
Demonstrate stabilization of mood, including absence of mania and suicidal depression.
●
Engage in normal activities of daily living and report subjective improvement in mood.
●
Demonstrate understanding of drug action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
●
Monitor mental and emotional status.
● Instruct the patient to keep a symptom log
Observe for mania and/or extreme
to document response to medication.
depression. (Lithium should prevent
mood swings.)
●
Monitor electrolyte balance. (Lithium is
Instruct patient to:
a salt affected by dietary intake of other
 Monitor dietary salt intake; consume
salts such as sodium chloride. Insufficient
sufficient quantities, especially during
dietary salt intake causes the kidneys to
illness or physical activity.
conserve lithium, increasing serum
 Avoid activities that cause excessive
lithium levels.)
perspiration.
Monitor fluid balance. (Lithium causes
Instruct patient to:
polyuria by blocking effects of antidiuretic
● Increase fluid intake to 1 to 1.5 L per day.
hormone.)
● Limit or eliminate caffeine consumption
(caffeine has a diuretic effect that can cause
 Measure intake and output.
lithium sparing by the kidneys).
 Weigh patient daily. (Short-term changes
● Notify healthcare provider of excessive
in weight are a good indicator of
weight gain or loss, or pitting edema.
fluctuations in fluid volume. Excess fluid
volume increases the risk of HF; pitting
edema may signal HF.)

Instruct patient to:
Monitor renal status. (Lithium may cause
● Immediately report anuria, especially
degenerative changes in the kidney which
accompanied by lower abdominal
increases drug toxicity.) Monitor laboratory
tenderness, distention, headache, and
tests: CBC, differential, BUN, creatinine,
diaphoresis.
uric acid, and urinalysis. Use with caution
● Inform healthcare provider of nausea,
in kidney disease.
vomiting, diarrhea, flank pain or tenderness
and changes in urinary quantity and quality
(e.g., sediment).
Monitor cardiovascular status. (Lithium
Instruct patient to:
toxicity may cause muscular irritability
● Immediately report palpitations, chest pain,
resulting in cardiac dysrhythmias or angina.)
or other symptoms suggestive of myocardial
●
Monitor vital signs including apical pulse.
infarction.
●
Use with caution in patients with a history ● Monitor vital signs ensuring proper use of
of CAD or heart disease.
home equipment.
●
Monitor gastrointestinal status. (Lithium ● Instruct patient to take the drug with food
may cause dyspepsia, diarrhea, or metallic
to reduce stomach upset and report
taste.)
distressing GI symptoms.
● Monitor metabolic status. (Lithium may
● Instruct patient to report symptoms of goiter
cause goiter with prolonged use and falseor hypothyroidism: enlarged mass on neck,
positive results on thyroid tests.)
fatigue, dry skin, or edema.
Evaluation of Outcome Criteria
Evaluate effectiveness of drug therapy by confirming that patient goals and expected outcomes
have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Methylphenidate (Ritalin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Risk for Delayed Development, related to
growth retardation secondary to
 Obtain complete health history including
allergies, drug history, and possible drug
methylphenidate.
interactions.
 Delayed Growth and Development, related
to increased motor activity, growth
 Obtain history of neurological, cardiac,
renal, biliary, and mental disorders
retardation secondary to methylphenidate,
including blood studies: CBC, platelets,
unsuccessful interpersonal relationships.
liver enzymes.
 Imbalanced Nutrition: Less than Body
 Assess neurologic status, including
Requirements, related to side effect of
identification of recent behavioral
medication.
patterns.
 Deficient Knowledge, related to drug
therapy.
 Assess growth and development.
 Disturbed Sleep Pattern, related to possible
side effect of medication.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Experience subjective improvement in attention/concentration and reduction in impulsivity
and/or psychomotor symptoms ("hyperactivity").
 Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions.
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
●
Monitor mental status and observe for
● Instruct patient to report any significant
changes in level of consciousness and
increase in motor behavior, changes in
adverse effects such as persistent
sensorium, or feelings of dysphoria.
drowsiness, psychomotor agitation or
anxiety, dizziness, trembling, or
seizures.
●
Use with caution in epilepsy. (Drug
● Instruct patient to discontinue drug
may reduce the seizure threshold.)
immediately if seizures occur and notify
healthcare provider.
●
Monitor vital signs. (Stimulation of the
Instruct patient to:
CNS induces the release of
● Immediately report rapid heartbeat,
catecholamines with a subsequent
palpitations, or dizziness.
increase in heart rate and blood
● Monitor blood pressure and pulse,
pressure.)
ensuring proper use of home equipment.
●
Monitor gastrointestinal and nutritional
Instruct patient to
status including side effects such as
● Report any distressing GI side effects.
nausea/vomiting, anorexia, and
● Take the drug with meals to reduce GI
abdominal pain. (CNS stimulation
upset and counteract anorexia; eat frequent
causes anorexia and elevates BMR,
small nutrient and calorie dense snacks.
producing weight loss.)
● Weigh weekly and report losses over one
pound.
●
Monitor laboratory tests such as CBC,
differential, and platelet count. (Drug is
metabolized in the liver and excreted by
the kidneys; impaired organ function can
increase serum drug levels. Drug may
cause leukopenia and/or anemia.)
●
Monitor effectiveness of drug therapy.
●
Monitor growth and development.
(Growth rate may stall in response to
nutritional deficiency caused by
anorexia.)
Monitor sleep-wake cycle. (CNS
stimulation may disrupt normal sleep
patterns.)
●
Instruct patient to:
● Report shortness of breath, profound
fatigue, pallor, bleeding, or excessive
bruising (these are signs of blood
disorder).
●
Report nausea, vomiting, diarrhea, rash,
jaundice, abdominal pain, tenderness,
distention, or change in color of stool
(these are signs of liver disease).
●
Adhere to laboratory testing regimen for
blood tests and urinalysis as directed.
Instruct the patient to:
 Schedule regular drug holidays.
 Not discontinue abruptly as rebound
hyperactivity or withdrawal symptoms may
occur: taper the dose prior to starting a drug
holiday.
 Keep a behavior diary to chronicle
symptoms and response to drug.
 Safeguard medication supply due to abuse
potential.
● Instruct patient that reductions in growth
rate are associated with drug usage. Drug
holidays may decrease this effect.
Instruct patient that:
● Insomnia may be an adverse reaction.
● Sleeplessness can sometimes be
counteracted by taking the last dose no
later than 4 p.m.
● Drug is not intended to treat fatigue; warn
the patient that fatigue may accompany
wash-out period.
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 CHLORPROMAZINE (Thorazine)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Therapeutic regimen management,
ineffective
 Obtain complete medical history,
especially of mental illness, respiratory,
 Activity intolerance, risk for related to side
gastrointestinal, genitourinary disorders,
effect of drug
alcohol and illegal drug use. Include
 Knowledge deficient, related to drug action
blood studies: electrolytes, CBC, BUN,
and side effects
creatinine, HCG levels if indicated, and
 Constipation related to decreased intestinal
drug screens (for use of illegal drugs)
motility
 Obtain patient’s drug history to determine  Injury, risk for related to drug effects
possible drug interactions and allergies
Planning: Patient Goals and Expected Outcomes
The patient will:
 Experience relief of positive symptoms of schizophrenia, and relief of manic symptoms in
patients with schizo-affective disorder
 Demonstrate an understanding of the drug’s action by accurately describing drug side
effects and precautions, and measures to take to decrease any side effects.
 Adhere strictly to the recommended treatment
 Abstain from alcohol and illegal drug use
 Immediately report any occurrence of any adverse reactions
Implementation
Interventions and (Rationales)
Patient Education and Discharge Planning
 Monitor for EPS and NMS. Medications Teach patient and family to:
may be available to treat EPS. (Presence  Recognize tardive dyskinesia, dystonia,
of EPS may be sufficient reason for
akathesia, pseudoparkinsonism
patient to discontinue chlorpromazine;
 Recognize and seek treatment immediately
NMS is life-threatening and must be
for elevated temperature, unstable blood
reported and treated immediately.)
pressure, profuse sweating, dyspnea, muscle
rigidity, and incontinence
Teach patient/family:
 Monitor for “cheeking”, hoarding or
sharing medication. Observe patient
 Importance of taking medication exactly as
closely for noncompliance. (If
ordered, and not sharing it with anyone
therapeutic results are not seen, patient
 How to check to be sure patient has
may not be taking medication as ordered,
swallowed medication
even though he/she may appear to be
taking it.)
Instruct patient to:
 Observe for side effects such as
orthostatic hypotension, constipation,
 Change position and arise slowly
anorexia, GU problems, respiratory
 Not to drive a car until he/she is stabilized
changes, visual disturbances. (These side
on chlorpromazine and sedating effects are
effects are caused by the anticholinergic
known
effects of chlorpromazine.)
 Report vision changes
 Comply with required laboratory tests as
ordered, e.g, Thorazine levels, electrolytes,
CBC, BUN, and creatinine.
 Increase roughage in diet, increase fluids,
and increase exercise to decrease or avoid
constipation
Instruct patient:
 Monitor for use of medication.
(Medication must be gradually
 To continue taking the medication as
withdrawn over a 2-3 week time, or
ordered, even if not therapeutic benefits are
patient may experience nausea/vomiting,
felt.
dizziness, tremors, or dyskinesia.)
 That it may take 6 weeks-6 months for full
therapeutic benefits.
 Monitor patient for respiratory
 Instruct patient that if any respiratory
depression, laryngospasm, dyspnea.
symptoms occur, their health care provider
must be notified.
 Monitor for caffeine use. (Caffeine will
 Instruct patient to avoid caffeine in common
cause a decreased therapeutic response of
products contain caffeine, including: coffee,
chlorpromazine.)
tea, carbonated beverages, and chocolate.
Instruct patient:
 Monitor patient’s environment.
(Chlorpromazine may cause patient to
 Wear dark glasses to avoid discomfort from
perceive brownish discoloration of
photophobia
objects or photophobia. Chlorpromazine
 Avoid temperature extremes.
may also interfere with the body’s ability
to regulate body temperature.)
 Observe for evidence of alcohol/illegal
 Instruct the patient to refrain from
drug use. (The patient may use
alcohol/illegal drug use.
alcohol/illegal drugs as means as coping
with symptoms of psychosis.)
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 CLOZAPINE (Clozaril)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Anxiety related to disease process
 Assess for hallucinations, mental status,
 Injury, risk for related to effects of drug
dementia, bipolar disorder (initially and
 Noncompliance, related to side effects of
throughout therapy).
drug
 Obtain complete medical history,
 Sleep pattern, disturbed, related to drug
especially psychological, neurologic and
effect
blood diseases: including blood studies:
 Knowledge deficient, related to drug action
CBC, WBC with differential, electrolytes,
and side effects
BUN, creatinine, liver enzymes.
 Obtain patient’s drug history to determine
possible drug interactions and allergies.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Report a reduction of psychotic symptoms, including delusions, paranoia, irrational
behavior
 Demonstrate an understanding of the drug’s action by accurately describing drug side
effects and precautions, and measures to take to decrease any side effects
 Adhere to recommended therapy, including medications, psychotherapy, health care
provider and lab appointments
 Refrain from alcohol, caffeine, smoking, other CNS depressants
Implementation
Interventions and (Rationales)
Patient Education and Discharge Planning
 Monitor RBC and WBC counts. If WBC
 Advise patient of the importance of having
levels drop < 3500, medication will need to
weekly lab studies done.
be stopped immediately. (Patient may be
developing agranulocytosis, which could
be life-threatening.)
 Monitor for hematologic side effects.
 Instruct patient to report immediately any
(Neutropenia, leukopenia, agranulocytosis,
sore throat, signs of infection, fatigue,
thrombocytopenia may occur, secondary to
bruising, without apparent cause.
possible bone marrow suppression caused
by clozapine.)
 Observe for side effects such as
 Instruct patient to report side effects to the
drowsiness, sedation, dizziness, depression,
health care provider.
anxiety, tachycardia, hypotension,
nausea/vomiting, excessive salivation,
urinary frequency or urgency,
incontinence, weight gain, muscles pain or
weakness, rash, fever. Report immediately.
Inform patient that:
 Monitor for side effects: mouth dryness,
constipation, urinary retention. Urinary
 Mouth dryness and constipation can be
retention may be corrected only by use of
decreased with sugarless gum or candy,
an indwelling catheter.


Monitor for decrease of psychotic
symptoms. (Medication is working as it
should if patient exhibits more normal
thoughts and behaviors. If patient
continues to exhibit symptoms of
psychosis, either he is not taking
medications as ordered, he is taking an
inadequate dose, or he is immune to it and
it will need to be discontinued and another
anti-psychotic begun.)
Monitor for alcohol use. (Alcohol used
concurrently with clozapine will cause
increased CNS depression. Patient may
decide to stop taking clozapine because he
wishes to use alcohol.)
increased fluids, frequent sips of water,
increased fruits and vegetables in diet
 If urinary retention occurs, notify health
care provider immediately to prevent
complications
Teach patient/family to:
 Look for more normal behaviors (completing
own ADLs, showing more interest in
surroundings, more normal sleep patterns,
etc.), to notice decrease or absence of
symptoms of psychosis, including
hallucinations, delusions, paranoia, etc.
 Contact health care provider if no decrease of
symptoms occurs over a six week period
Instruct patient:
 Refrain from alcohol use; refer to Alcoholics
Anonymous or another support group if
indicated
 Take medication as ordered; do not stop
medication and drink alcohol
 Discourage caffeine use. (Use of caffeine Inform patient of common caffeinecontaining substances will negate effects of
containing products, including coffee, tea,
clozapine.)
carbonated beverages, chocolate, etc.
 Encourage smoking cessation. (Heavy
 Instruct patient to stop or decrease smoking;
smoking may decrease blood levels of
refer to smoking cessation programs if
clozapine.)
indicated.
 Monitor elderly closely, and give lower
 Teach elderly patients ways to counteract
doses. (They may be more sensitive to
anticholinergic effects of medication, while
anticholinergic effects.)
taking into account any other existing
medical problems.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes
have been met (see “Planning”).