Nursing Process Focus:
Patients Receiving Ciprofloxin (Cipro)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Deficient Knowledge related to
antibacterial drug therapy
 Obtain complete health history including
allergies, drug history and possible drug
 Risk for fluid volume deficit related to GI
interactions
side effects from drug therapy
 Assess for presence or history of local or
 Diarrhea, related to effects of drug therapy
systemic infections
 Obtain vital signs
 Obtain history of drug allergies
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of drug therapy
 Demonstrate evidence of resolution of diagnosed infection after drug therapy is completed
 Maintain adequate fluid and electrolyte balance
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Safety for use by children under 18 not
 Instruct patient to contact health care
established, due to possible action of Cipro
provider at the first signs of tendon pain
on the cartilage, usually the Achilles
or inflammation.
tendon: tendon rupture. (May interfere with
bone development in children less than 18
years of age.)
 Avoid administering medications or foods
 Instruct patient to administer these
that contain calcium, iron, or zinc such as
substances and medications 2 hours
antacids, dairy products, sucralfate or
after ciprofloxacin.
vitamin or mineral supplements, within 2
hours..
 Administer with water and maintain
 Take each dose with a glass of water
adequate fluid intake to avoid crystalluria.
and drink several extra glasses of fluid
daily to prevent formation of
 Monitor intake and output and urine pH.
ciprofloxacin crystals in the urine.
(The drug alters urinary pH and causes
crystals to form in urine.)
 Monitor use of caffeine during drug
 Instruct patient to avoid caffeine intake
therapy. (Absorption of Cipro is decreased
during drug therapy.
by caffeine.)
 Monitor plasma theophylline
 Inform patient that serum levels will
concentrations for patients prescribed these
need to be monitored.
drugs. (The drug affects half-life of
theophylline preparations.)
 Monitor patient for symptom of dizziness
 Advise patient to use caution when
or lightheadedness. (This may occur due to
driving, operating machinery, or
the action of ciprofloxacin on the central
performing other hazardous activities
nervous system (CNS).)
until effect of drug is known.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
Patients Receiving Trimethoprim (Bactrim, Septra)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Infection, Risk related to contact with
contagious agents (nosocomial or
 Obtain complete health history including
allergies, drug history and possible drug
community acquired)
interactions
 Infection, Risk related to increased
vulnerability secondary to diminished
 Assess for presence or history of systemic,
respiratory or urinary tract infection
immune response
 Assess intake and output
 Knowledge, Deficient, related to drug
therapy and side effects
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate reduction in symptoms related to the diagnosed infection
 Demonstrate understanding of drug therapy and side effects
 Remain free of symptoms of side effects of drug therapy
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Inform patient:
 Monitor renal function including BUN
and creatinine values, and intake and
 That creatinine clearance tests and BUN
output.(Drug can cause hematological
may need to be monitored
toxic effects, which are increased with
 To report changes in urinary elimination to
kidney disease and also the elderly
the health care provider
population.)
Advise patient to:
 Evaluate complaints of painful urination,
flank pain, and fever. (Drug can change
 Drink 2.5-3 liters of fluid daily.
the urine pH and could increase the
 Report painful urination, flank pain or
patient’s risk for formation of renal
fever to the health care provider
calculi.)
 Monitor baseline and follow-up urinalysis,  Instruct patient to continue medical
CBC, platelet count, BUN and creatinine
follow-up and laboratory test appointments
clearance with long-term therapy. (To
when receiving drug for extended period
evaluate effectiveness of drug therapy.)
of time.
 Observe for symptoms of adverse
 Instruct patient to report skin rash, sore
reactions. (Evidenced in hematology and
throat, fever, mouth sores, or unusual
blood coagulation studies and by skin
bleeding or bruising.
manifestations.)
 Monitor skin integrity. (This drug can
 Instruct patient to avoid exposure to direct
also increase patient’s sensitivity on the
sunlight and sunlamps.
skin to ultraviolet lights.)
 Monitor compliance with treatment
 Instruct patient to take drug as directed and
regimen. (Full course of therapy is
to complete full prescription.
required. If patient stops medication
before prescription is complete, symptoms
may reoccur and this may increase
resistance to further antibiotics.)
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 Penicillin G (Pentids)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Infection, Risk for, related to weakened
immune state or contact with pathogen
 Obtain complete health history including
allergies, drug history and possible drug
 Knowledge deficient related to drug action
interactions.
and therapy treatment and prevention
measures
 Assess for presence or history of local or
systemic infection.
 Injury, Risk (anaphylaxis) for related to
 Obtain vital signs
adverse effects of drug
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of signs of allergic reaction to drug therapy
 Demonstrate knowledge of drug action and side effects
 Demonstrate resolution to incidence of infection
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Monitor for evidence of allergic reaction Instruct patient:
to drug. (Allergic reaction may occur
 Signs of allergic reaction including
immediately or delayed beyond 72
itching, rash, respiratory distress
hours.)
 To immediately contact the health care
provider if allergic reaction occurs
 Monitor intake and output especially
 Advise patient to consult health care
quantity and consistency of bowel
provider before taking antidiarrheal
movements. (Severe diarrhea may occur
medication. These medications may
due to the possible adverse effect from
worsen or prolong diarrhea.
Pseudomembranous colitis.)
 Evaluate patient’s understanding of drug Instruct patient to:
therapy and administration.
 Take medication one hour before or two
hours after a meal.
 Give medication on empty stomach to
reduce destruction by gastric acid and
 Take medication with glass of water
enhanced absorption.
 Take all of medication unless instructed
to discontinue by the health care provider
 Evaluate patient for evidence of
 Instruct patient to notify the health care
resolution of infectious process. (If the
provider if symptoms persist or worsen.
prescribed antibacterial is not effective
another medication or different dosage
may be required.)
 Observe for superinfection, especially in
 Instruct patient to report signs and
susceptible patients including elderly,
symptoms of superinfection. Symptoms
debilitated, or immunosuppressed patient.
may include: fever, black hairy tongue,
(There is a high risk for superinfections
stomatitis, loose, foul-smelling stools,
due to normal flora reduced or
vaginal discharge, or cough.
eliminated.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes are met (see “Planning”).
Nursing Process Focus:
Patients Receiving Cefotaxime (Claforan)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Injury, Risk for (Allergic reaction) related
to adverse reaction to drug
 Obtain complete health history including
allergies, drug history and possible drug
 Infection, Risk for superinfection related to
interactions
effects of drug therapy
 Assess for presence of local or systemic
 Fluid volume, Risk for deficit, related to
infection
effects of drug on GI system
 Obtain vital signs
 Diarrhea, Risk for related to side effects of
drug
 Obtain history of drug allergies
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of symptoms of allergic reaction
 Maintain adequate fluid balance
 Demonstrate absence of superinfection
 Maintain formed stool consistency
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to:
 Monitor for severe diarrhea caused by
the disruption of normal bowel flora.
 Report loose stools or diarrhea.
(May cause fluid electrolyte imbalance
 Avoid treating diarrhea with
and superinfection of antibioticantidiarrheals as this can impede the
associated pseudomembranous Colitis.
process of eliminating “bad bacteria"
Cultured dairy products with live active
 Check with health care provider before
cultures, such as kefir or yogurt may be
taking any probiotic products.
used to help maintain normal intestinal
flora. Supplements containing
beneficial bacterial, such as
acidophilus, are also available OTC).
 Monitor for rash, pruritus, or fever
 Instruct patient to report adverse
(indicative of an allergic reaction to the
reactions promptly.
medications).
 Monitor intake and output carefully in
 Explain to patient purpose of required
patients with compromised renal
laboratory tests and schedule follow-up
function or if receiving
with health care provider.
aminoglycoside.
 Monitor renal function with lab studies
periodically during and after therapy.
(Toxicity could occur from drug toxins
that are unable to be excreted.)
 Monitor for superinfection, especially
 Instruct patient to report symptoms,
with prolonged therapy.
especially in debilitated or chronically ill
patient.
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 Tetracycline HCl (Achromycin and others)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Body image, disturbed related to change in
appearance
 Obtain complete health history including
allergies, drug history and possible drug
 Noncompliance related to prolonged
interactions.
therapy
 Assess for presence/history of: Lyme
 Therapeutic regimen management,
disease, pneumonia, acne vulgaris,
Ineffective related to prolonged course of
Typhus, Cholera, Rocky Mountain
treatment
spotted fever, Chlamydia, sexually
 Knowledge, Deficient, related to drug
transmitted diseases, bladder infections,
action and side effects
Helicobacter Pylori ulcers
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of symptoms caused by the diagnosed infection.
 Maintain positive body image
 Demonstrate knowledge of drug therapy and side effects
 Demonstrate compliance with drug regimen
Implementation
Interventions and (Rationales)
 Monitor dental status when administered
to children under age 8. (Drug may
cause permanent discoloration of teeth,
enamel defects, and bone growth
retardation.)
 Administer with caution to patients with
impaired kidney or liver function. (Could
result in impaired metabolism and
excretion.)


Evaluate use of OTC products such as
antacids, calcium supplements, iron
products, and laxatives containing
magnesium. (These products interfere
with drug absorption).
Evaluate patient understanding of drug
therapy and administration. (Drug may
cause photosensitivity and increase risk
of sunburn. Tetracyclines can increase
patient’s sensitivity of the skin to
ultraviolet light.)
Patient Education/Discharge Planning
 Instruct patient and caregivers to report
evidence of tooth discoloration or dental
abnormalities to health care provider.
Instruct patient to:
 Report changes in urinary output
 Report for follow up care and lab tests of
kidney and liver function and serum
tetracycline levels.

Instruct patient to consult with health care
provider before taking over the counter
drugs.
Instruct patient to:
 Avoid direct exposure to sunlight during
and after therapy. Wear protective
clothing, sunglasses and sunscreen.
 Use an alternate form of birth control
until all the medication is completed.
 Avoid taking drug with food, especially
dairy products
 Report adverse effects of topical agent
may cause irritation to eyes, nose, mouth,
or allergic reaction.
 To report worsening of infection and
burning sensation to health care provider.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes are met (see “Planning”).
Nursing Process Focus:
Patients Receiving Erythromycin (E-mycin, Erythrocin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Knowledge, Deficient related to disease
process and drug therapy
 Obtain complete health history
including allergies, drug history and
 Infection, Risk for related to superinfection
possible drug interations.
 Fluid volume, Risk for Deficit related to
 Assess for presence/history of local or
effects of drug on GI system
systemic infection
 Diarrhea, Risk forrelated to effect of drug
 Obtain vital signs
therapy
 Obtain history of allergic reaction to
 Injury, Risk for (anaphylaxis) , related to
drugs
adverse reaction to drug
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate knowledge or drug therapy and treatment regimen
 Remain free of drug induced diarrhea
 Maintain adequate fluid balance
 Maintain absence of allergic reaction to drug
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
 Contraindicated in patients with hepatic
 Instruct patient to report history of medical
disease. (Because the metabolism of
problems to health care provider.
erythromycin ethylsuccinate (EES) is
mainly by the liver, it increases the
patient’s risk for toxicity.)
 Monitor WBC, temperature, cultures, and Instruct patient:
perform infection-focused physical
 To report fever and worsening symptoms
examination. (To determine effectiveness
of infection.
of drug therapy.)
 To report for follow-up examinations.
Instruct patient:
 Evaluate patient understanding of
treatment regimen. (Patient must
 To complete full prescription even if
complete full course of therapy to prevent
feeling better or symptom free.
bacterial resistance.)
 Take with full glass of water, on an empty
stomach one-hour before or two hours
after meals.
 Avoid taking with or just after acidic fruit
juices or carbonated drinks.
 Monitor for evidence of G.I. distress.
 Instruct patient to report past history of GI
(May require alternate form of
problems to health care provider.
medication.)

Monitor for ototoxicity in patients
receiving high dose, older adults,
female and history of kidney or liver
dysfunction.

Instruct patient to immediately report
dizziness, vertigo, nausea, tinnitus, roaring
noises, or hearing impairment to the health
care provider.

Observe for signs and symptoms of
 Instruct patient to report diarrhea,
superinfection by overgrowth of nonabdominal pain, vaginal discharge, or
susceptible bacteria or fungi.
fever.
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 Gentamicin (Garamycin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Injury, Risk for related to renal
insufficiency related to aminoglycoside
 Obtain complete health history including
allergies, drug history and possible drug
therapy
interactions
 Injury, Risk for related to disturbances of
balance and impaired ability to detect
 Assess for presence/history of local or
systemic infection
environmental hazards
 Obtain vital signs
 Knowledge, Deficient related to drug
therapy and side effects
 Obtain history of drug allergies
Planning: Patient Goals and Expected Outcomes
The patient will:
 Maintain normal renal function throughout drug therapy.
 Demonstrate knowledge of drug therapy and side effects
 Remain free of physical injury
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to provide thorough history of
 Use with caution with impaired renal
medical conditions and treatment to health care
function or neuromuscular disorders.
provider.
(Renal impairment can increase the risk
of toxicity with this drug. Patients with
neuromuscular disorders may experience
greater muscular weakness due to
possible neuromuscular blockade with
the drug’s action.)




Monitor for signs of renal toxicity
including unusual appearance of urine
(dark, cloudy) intake and output ratio,
and the presence of edema. Report
immedately
Monitor for evidence of ototoxicity
including headache, dizziness or
vertigo, nausea or vomiting with motion,
ataxia, nystagmus, tinnitus, roaring
noises, sensation of fullness of ears and
hearing impairment.
Monitor peak and trough drug levels.
(Aminoglycosides have a narrow
therapeutic range.)
Observe for symptoms of neurotoxicity
or neuromuscular blockade.
Instruct patient to:
 Increase fluid intake of 2000 ml per day.
 Report evidence of decreased urinary
output to the health care provider

Instruct patient to notify health care
provider if changes in hearing occur.

Explain to patient that frequent serum drug
therapy levels are necessary to prevent and
monitor for complications.
Instruct patient to immediately report
muscle twitching, numbness, seizures,
weakness, or difficulty breathing to the
health care provider.


Observe for signs and symptoms of
 Instruct patient to report diarrhea,
bacterial overgrowth due to drug’s effect
anogenital itching, vaginal discharge,
to “kill” all bacteria, even normal flora
stomatitis, or glossitis.
that can lead to superinfection.
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 Vancomycin (Vancocin)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Sensory perception, Disturbed related to
ototoxicity
 Obtain complete health history including
allergies, drug history and possible drug
 Injury, Risk for deep vein thrombosis
interactions
related to chemical irritation of vein
 Assess for presence or history of infections  Knowledge, Deficient, related to drug
resistant to other antibiotics
therapy and side effects
 Obtain history of hearing loss, impaired
renal function
 Obtain history of cardiovascular disease
 Obtain history of hearing loss
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate therapeutic response to drug therapy
 Remain free of phlebitis
 Maintain normal hearing acuity
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Inform patient:
 Evaluate hearing acuity. (Contraindicated
with previous hearing loss due to drug’s
 That audiometry tests will be done to
ototoxic effects.)
prevent complications from possible
ototoxicity.
 To report symptoms of hearing loss,
buzzing in ears

Monitor peak and trough vancomycin
levels to ensure safe and effective dosage.

Inform patient about purpose of laboratory
studies.

Monitor renal status. (Dosage is adjusted
with renal insufficiency.)

Advise patient of importance of laboratory
studies to establish baseline renal function
and to monitor function during and after
treatment.

Monitor IV site carefully. (Drug is
irritating to tissues and causes necrosis and
severe pain with extravasations.)

Instruct patient to report pain or other
symptoms of discomfort immediately
during intravenous infusion.

Monitor for proper use of medication.

Patient must take medication as prescribed
and complete full course of treatment. Do
not take other antidiarrheal preparations.
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 Isoniazid (INH)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Sensory perception, Disturbed related to
peripheral neuritis and optic neuritis
 Obtain complete health history including
allergies, drug history and possible drug
 Knowledge, Deficient, related to drug
interactions
therapy and side effects
 Assess for presence/history of Positive
 Therapeutic regimen management,
tuberculin skin test, positive sputum culture
Ineffective related to long term therapy
or smear, close contact with person
recently infected with tuberculosis, AIDS,
receiving immunosuppressant drugs,
alcohol abuse, liver or kidney disease
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate adherence to extended drug therapy
 Demonstrate negative sputum cultures indicating effective drug therapy
 Demonstrate understanding of drug therapy
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to:
 Monitor liver function. (Contraindicated in
patients with acute liver disease or history
 Provide accurate and complete medical,
of isoniazid-related liver damage.)
medication and treatment history.
 Avoid alcohol intake during drug therapy
 Report signs of liver impairment to health
care provider, including jaundice, itching,
fatigue
 Monitor for negative sputum cultures.
 Instruct patient to follow through on
Change noted within 2-3 weeks. (To
prescribed lab tests.
evaluate effectiveness of drug therapy.)
Instruct patient to:
 Monitor for presence of peripheral neuritis
related to pyroxidine deficiency.
 Take pyrodoxine supplement to reduce
(Pyrodoxidine (vitamin B6) deficiency
risk of side effects.
causes neurotoxic effects.)
 Report symptoms of numbness, tingling,
or burning of feet to the health care
provider
 Evaluate diet for ingestion of foods
 Advise patient to avoid foods such as
containing tyramine. (Ingestion of
aged cheeses, smoked fish, tuna,
tyramine-containing foods may cause
sauerkraut juice, and yeast extracts.
palpitation, flushing and BP elevation, and
histamine-containing foods may cause
exaggerated drug response with headache,
palpitation, sweating, flushing, itching, or
diarrhea.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).