Nursing Process Focus:
Patients Receiving Hepatitis B Vaccine (Recombinant)
Potential Nursing Diagnoses
Assessment
 Injury, Risk for related to side effects of
Prior to administration:
medication
 Assess for possible exposure to HBV.
 Knowledge, Deficient related to
Possible signs/symptoms include: fluadministration of medication
like symptoms, GI symptoms, joint or
RUQ pain, jaundice, clay-colored stool,
and/or dark urine. Those exposed to the
virus will need a combination therapy of
both the hepatitis B vaccine and the
Hepatitis B Immune Globulin
 Obtain blood work for those with
possible exposure: HBsAG viral
antigen/antibodies, complete blood
count, electrolytes, liver enzymes (ALT,
ALP, AST, GGT, & LDH), bilirubin
levels, and prothrombin time.
 Assess patient’s drug history/allergy to
determine possible sensitivity to baker’s
yeast or previous dose of hepatitis B
vaccine.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Complete the series of vaccinations according to recommended immunization schedule
 Remain free of signs and symptoms of Hepatitis B
Implementation
Interventions and (Rationales)
Identify “at risk populations” for Hepatitis.
These include
People who have more than one sex
partner in 6 months
Men who have sex with other men
Sex contacts of infected persons
People who inject illegal drugs
Health care and public safety workers
Household contacts of persons with
chronic HBV
Hemodialysis patients
 Monitor for flu-like symptoms. Those who
are ill should wait until they recover before
getting the vaccine.
Patient Education/Discharge Planning
 Educate at “risk populations” concerning
the availability of immunizations
throughout the community; i.e., local health
departments and clinics.

Instruct patient to report any flu-like
symptoms, GI upset, changes in urine or
stool color before getting vaccine

Ensure infants receive the vaccine
according to recommended schedule
Instruct infant caregivers of immunization
schedule:
 within 12 hours of birth
 2nd dose: 1-2 months of age
 3rd dose: 6 months of age.
The third dose should not be given before 6
months of age because this could reduce longterm protection.

Ensure older children, adolescents or
adults receive the vaccine according to
recommended immunization schedule.

Monitor for common side effects such as
soreness at injection site and fever
Instruct patient of immunization schedule:
 1st dose: anytime
 2nd dose: 1-2 months after first dose
 3rd dose: 4-6 months after first dose
If dose is missed, next dose should be received
as soon as possible.
 Instruct patient to notify health care
provider if fever occurs or soreness at
injection site lasts longer than a couple of
days.
 Instruct patient to notify health care
provider of any signs or symptoms of an
allergic reaction

Monitor for possible allergic reactions
such as difficulty breathing, hoarseness or
wheezing, hives, paleness, weakness,
tachycardia or dizziness.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Interferon Alfa 2A (Roferon A, Intron A)
Potential Nursing Diagnoses
Assessment
 Injury, Risk for related to side effects of
Prior to administration:
medication
 Assess for presence/history of
Cytomegalovirus and any malignancies for  Nutrition Altered, Risk for related to
gastrointestinal upset secondary to
verification of need.
medication
 Also check for pancreatitis, hepatic or renal
 Infection, Risk related to bone marrow
disease, bone marrow depression, and/or
suppression secondary to medication
cardiac disease. Interferon may be

Knowledge, Deficient related to
contraindicated for patients with these
administration of medication
disorders.
 Obtain blood work: complete blood count,
electrolytes, and liver enzymes
 Obtain weight, and vital signs especially
blood pressure
 Assess mental alertness
 Assess patient’s drug history/allergy to
determine possible sensitivity to interferon
alpha or its components
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of fever, chills, sore throat, unusual bleeding, chest pain, palpitations,
dizziness, change in mental status
 Demonstrate the ability to self administer IM or SC injection
 Maintain consumption of balanced diet
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct patient to:
 Monitor for leukopenia, neutropenia,
thrombocytopenia, anemia, increased liver
 Comply with all ordered laboratory tests
enzymes (due to possible bone marrow
 Immediately report an unusual bleeding
suppression and liver damage).
and jaundice
 Avoid crowds and people with infections
 Ensure medication is properly
 Instruct patient in proper technique for
administered.
self administration of IM or SC injection.

Monitor vital signs including temperature,
pulse respirations and blood pressure.
(Loss of vascular tone leading to
extravasation of plasma proteins and
fluids into extravasular spaces may cause
hypotension and arrhythmias.)
Instruct patient to:
 Monitor blood pressure and pulse
everyday and report to health care
provider any reading outside normal
limits
 Report any palpitations to health care
provider immediately


Monitor for common side effects such as
muscle aches, fever, weight loss, loss of
appetite, nausea and vomiting and
arthralgia due to high doses of
medications. Report to health care
provider.
Instruct patient to:
 Take medication at bedtime to reduce side
effects
 Use frequent mouth care and small
frequent feedings to reduce
gastrointestinal disturbances
Monitor blood glucose levels. (Blood
 Instruct patient to have blood glucose
sugar may increase in patients with
checked at regular intervals.
pancreatitis.)
 Monitor for changes in mental status.
 Instruct patient to notify health care
(May cause depression, confusion,
provider of any mental changes.
fatigue, visual disturbances, and
numbness. Alpha-interferons cause or
aggravate neuropsychiatric disorders.
Mechanism of action undetermined.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that the patient goals and expected
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Cyclosporine (Neoral, Sandimmune)
Assessment
Potential Nursing Diagnoses
Prior to administration
 Infection, Risk for related to depressed
immune response secondary to medication
 Assess for presence/history of organ
transplant, grafting, active infection, and
 Injury, Risk for related to thrombocytopenia
pregnancy
secondary to side effects of medication
 Assess for skin integrity, specifically look
 Knowledge, Deficient, related to drug action
for lesions and skin color
and side effects
 Obtain blood work: complete blood count,
electrolytes, and liver function
 Obtain vital signs especially temperature
and blood pressure
 Assess patient’s drug history/allergy to
determine possible sensitivity to
polyoxyethylated castor oil
Planning: Patient Goals and Expected Outcomes
The patient will:



Remain free of elevated temperature, unusual bleeding, sore throat, mouth ulcers, fatigue
Demonstrate complianewith all laboratory tests needed to monitor this medication
Demonstrate understanding of signs and symptoms of side effects related to medication
Implementation
Interventions and (Rationales)
 Monitor renal function. (May cause
nephrotoxicity. 75% of patients experience
decreased urine flow due to changes
physicological in the kidneys such as
microcalcification and interstitial fibrosis.)
 Monitor liver function (due to an increased
risk for liver toxicity).


Patient Education/Discharge Planning
Advise patient to:
 Keep good record of urine output
 Report significant reduction in urine follow
to the health care provider

Instruct the patient concerning the
importance of regular blood work.
Watch for signs and symptoms of infection. Instruct patient:
(There is an increased risk of infection.)
 Regarding importance of good, frequent
handwashing.
 To avoid crowds and anyone who has
infection
Monitor vital signs especially temperature
 Teach patients to monitor blood pressure
and blood pressure. (As a side effect of this
and temperature ensuring proper use of
medication especially related to those with
home equipment and compliance with
kidney transplants, hypertension may occur
doctor’s appointments.
in 10-15% of patients. Increased
temperature may indicate infection.)

Advise patient to:
 See a dentist on a regular basis.
 Comply with regular laboratory assessments
(complete blood count, electrolytes, and
hormones levels)
 Monitor nutritional status (due to possible
 Instruct patient in a healthy diet that avoids
weight gain).
excessive fats and sugars.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes
have been met (see “Planning”).
Monitor for the following possible side
effects: hirsuitism, leukopenia, gingival
hyperplasia, gynecomastia, sinusitis and
hyperkalemia
Nursing Process Focus:
Patients Receiving Prednisone (Meticorten)
Potential Nursing Diagnoses
Assessment
 Nutrition: more than body requirements,
Prior to administration:
Risk for Imbalanced: related to weight
 Obtain complete drug history including
gain from medication
allergies, drug history and possible drug
 Fluid volume, Excess related to fluid
interactions
retention secondary to medication
 Assess vital signs
 Body image, Disturbed related to
 Assess for history of organ transplant,
physical changes secondary to
acute inflammation, diabetes mellitus
medication
 Obtain serum electrolytes
 Injury, Risk for (infection) related to
immunosuppression from medication
 Skin Integrity, Risk for Impaired related to
tissue fragility secondary to medication
Planning: Patient Goals and Expected Outcomes
The patient will:
 Maintain body weight within normal range
 Remain free of edema in lower extremities
 Demonstrate positive body image
 Maintain intact skin integrity
Implementation
Interventions and (Rationales)
 Monitor vital signs, especially blood
pressure (to determine need for possible
treatment of fluid and electrolyte disorders
and renal insufficiency).
 Use cautiously in patients with renal
insufficiency (due to the drug’s ability to
retain water and sodium and the main
excretion of drug is by the renal system).
 Monitor complete blood count. (Capillaries
become more permeable resulting in
vasoconstriction. Red blood cells increase,
causing decrease in white blood cells.)
 Obtain medical history of myasthenia gravis
(due to the possible adverse effect of
exacerbation of respiratory failure).
 Monitor blood sugar. (Use cautiously in
patients with diabetes mellitus due to drug’s
effect on blood sugar, causing
hyperglycemia. Patients may require
increased doses of a glucose-lowering
drug.)
Patient Education/Discharge Planning
 Inform patient to report to health care
provider any signs and symptoms of fluid
retention; e.g. increase in weight by 2 lbs in
a 1 week, swelling of hands and feet,
difficulty breathing.


Inform patient concerning the need to for
periodic lab testing
Instruct patient to report any difficulty in
breathing to health care provider
immediately.
Instruct patient:
 May increase insulin needs while on this
medication
 To increase blood sugar monitoring and to
report increased blood sugar to health care
provider.


Monitor for signs and symptoms of
infection or inflammation. (Medication may
mask usual signs of infection. Use
cautiously in patients with acute active
infections. Contraindicated in patients with
systemic fungal infection due to the
possibility of interaction with the acute
infection and the risk for superinfections.)
Monitor compliance with medication
regimen.
Instruct patient to:
 Avoid all contact with individuals with
infections
 Wash hands frequently and to clean all
counters completely after food
preparation
Instruct patient:
 Take medication exactly as scheduled and
to never abruptly stop medication.
 Avoid taking any OTC drugs without
checking with the health care provider.
Instruct patient to:
 Monitor intake and output (due to drug’s
ability to cause water and sodium retention).
 Weigh self regularly
 Report any sudden weight gain to the
health care provider
Advise
patient to take medication with food to
 Obtain history of gastrointestinal disorders.
decrease gastrointestinal distress.
 (Use cautiously in patients with active
peptic ulcer disease due to inhibiting
production of cytoprotective mucous and
reduction of GI mucosal blood flow that can
lead to gastric ulceration.)
 Use extreme care during venipuncture due
 Advise patient to carry some form of
to capillary fragility. (Capillary fragility is
identification stating the medication the
due to the suppression of protein synthesis
patient is taking.
by the glucocorticoids’ effect.)
 Evaluate risk for osteoporosis. (Use
 Advise patient to consume nutritious low
cautiously in patients with osteoporosis due
calorie foods and to increase dietary
to drug’s effect to cause suppression of bone
calcium to combat osteoporosis.
formation by osteoblasts, hence to worsen
symptoms of osteoporosis.)
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 Acetaminophen (Tylenol)
Potential Nursing Diagnoses
Assessment
 Pain related to ineffective response to
Prior to administration:
medication
 Obtain complete health history including
 Injury, Risk for hepatic toxicity) related
allergies, drug history and possible drug
to adverse effects of medication
interactions.

Knowledge, Deficient related to drug
 Obtain history of liver disease
action and side effects
 Assess history of pain or fever
 Obtain concurrent use of anticoagulants
 Obtain intolerance to ASA
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate an understanding of safe self administration of medication.
 Demonstrate relief of pain
 Remain free of evidence of hepatic toxicity
Implementation

Interventions and (Rationales)
Monitor for evidence of liver dysfunction
(due to acetaminophen accumulation, and
resulting liver damage).

Monitor renal function tests, and intake and
output (due to the ability of acetaminophen
to impair renal function as a result of toxic
levels).

Monitor concurrent medication use. (Be alert
to all other medications that contain
acetaminophen especially in combination with
narcotic pain reliever to avoid toxic levels.
Contraindicated for use with warfarin due
to the mechanism of inhibition of warfarin
metabolism, which causes warfarin to
accumulate at high levels.)
Observe for intolerance to ASA for possible
cross-hypersensivity to acetaminophen.



Monitor for signs of infection, including
complete blood count and platelet count.
(Acetominophen’s effects may mask
infection.)
Patient Education/Discharge Planning
Advise patient to:
 Abstain from alcohol while taking this
medication.
 Report signs of liver dysfunction
including jaundice, itching, fatigue
Advise patient:
 Lab tests to assess renal function may be
necessary to prevent renal tubular
necrosis.
 To notify health care provider if changes
in urinary output occurs.
Advise patient to:
 Avoid taking any other OTC medication
unless ordered by health care provider.
 Read directions carefully when using
acetaminophen suspension and drops
 Not to exceed recommended daily dose of
medication

Instruct patient to report any itching, skin
rash, or difficulty breathing.

Instruct patient to report signs of infection
generalized mild muscular pain and
headache.

Monitor pain level (to determine
 Instruct patient to report changes in pain
effectiveness of drug therapy).
level to health care provider.
 Monitor blood sugar in patients with
 Advise patient that this medication may
diabetes mellitus. (Acetaminophen may
cause hypoglycemia.
decrease insulin needs.)
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 Diphendrydramine (Benadryl)
Potential Nursing Diagnoses
Assessment
 Injury, Risk for related to drowsiness
Prior to administration:
and dizziness secondary to effects of
 Obtain complete health history
medication
including allergies, drug history and
 Gas exchange, Risk for Impaired related
possible drug interactions
to respiratory secretions
 Obtain presence/history of allergic or
 Knowledge, Deficient related to drug
anaphylactic reactions
action and side effects.
 Obtain vital signs
 Obtain history of glaucoma, diabetes
mellitus, seizure disorder
Planning: Patient Goals and Expected Outcomes
The patient will:
 Remain free of physical injury
 Demonstrate knowledge of drug therapy and side effects
 Remain demonstrate relief of symptoms of allergic reaction
Implementation





Interventions and (Rationales)
Monitor vital signs before, during, and after
administration (due to anticholinergic effect
on vital signs of decreased BP and increased
heart rate).
Obtain history of narrow angle glaucoma
and increased intraocular pressure. (Drug
may worsen condition.)
Obtain history of prostatic hypertrophy and
bladder neck obstruction. (Both conditions
are contraindicated for use with
diphenhydramine due to exacerbation by
anticholinergic effects and muscarinic
blockade.)
Monitor for respiratory conditions. (Drug
may worsen conditions such as asthma.)
Monitor for GI conditions and distress.
(Drug interferes with function of H1
receptors.)
Patient Education/Discharge Planning
Advise patient:
 That blood pressure may decrease and
heart rate increase
 To report changes in vital signs to health
care provider
 To monitor blood pressure and pulse
 Instruct patient to report history of
glaucoma to health care provider.

Instruct patient to report any urinary
obstruction or difficulty in voiding.
Instruct patient to:
 Report symptoms of respiratory distress to
the health care provider
 Increase fluid intake to make expectoration
easier
 Advise patient to take medication with
food to reduce gastrointestinal distress.





Obtain history of diabetes mellitus. (Use
cautiously in these patients due to the
possibility of this drug to increase
hypoglycemia.)
Monitor neurological status especially for
patients with history of seizures. (Use
cautiously in these patients due to
medication causing an increase in seizure
activity.)
Use cautiously in patients with history of
hyperthyroidism, cardiovascular disease.
(There is an increased risk of thyroid storm,
and cardiovascular collapse.)
Monitor for side effects such as dry mouth.
Advise patient to:
 Monitor blood sugar more frequently
 Inform health care provider of any
abnormally low blood sugar levels.
Instruct patients to:
 Report aura immediately to health care
provider
 Report increase of seizure activity to health
care provider
Advise patient to:
 Report any unusual effects such as
increased nervousness, insomnia.
 Report changes in vital signs
 Advise patient to suck on hard candy to
reduce symptoms of dry mouth.
Advise patient to:
 Refrain from driving or operating heavy
machinery due to sedating effects
 Report feeling of oversedation to the health
care provider
 Discontinue at least 4 days prior to skin
 Inform patient to notify health care
tests. (Drug may increase effect to the
provider if they are on any H1 receptor
testing and give a false positive result.)
antagonists.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes
have been met (see “Planning”).
Closely monitor elderly patients (because of
an increase incidence of dizziness, sedation
and hypotension).
Nursing Process Focus:
Patients Receiving Fexofenadine (Allegra)
Potential Nursing Diagnoses
Assessment
 Injury, Risk related to drug related
Prior to administration
drowsiness
 Obtain complete health history
 Knowledge Deficient, related to drug
including allergies, drug history an
action and side effects
possible drug interactions

Assess for presence/history of seasonal
allergic rhinitis, allergic conjunctivitis,
urticaria, angioedema
 Obtain vital signs
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of drug therapy
 Remain free of physical injury
Implementation
Interventions and (Rationales)
Monitor neurological status of elderly
patients. (The elderly are more prone to
syncope, sedation and dizziness due to long
acting effects of medication.)
Patient Education/Discharge Planning
Advise patient to:

 Avoid driving or operating heavy
machinery until drowsiness is no longer a
problem
 Resort symptoms of over sedation to health
care provider
 Monitor respiratory status prior to therapy
 Instruct patient to report any difficulty in
(due to anticholinergic effects on respiratory
breathing to health care provider
system).
 Monitor for renal impairment. (Use with
 Advise patient to report changes in urinary
caution in these patients due to aggravating
pattern or output.
factors related to muscarinic blockade.)
 Observe for allergic conditions, such as
 Instruct patient to report changes in
seasonal allergic rhinitis, allergic
allergic condition to health care provider.
conjunctivitis, and urticaria (to monitor
effectiveness of drug therapy).
 Monitor vital signs, especially heart rate and Advise patient to:
respiratory rate.
 Not take any OTC cold medications
without first checking with the health care
providerhealth care provider
 Abstain from the use of alcohol while
taking this medication
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 Fluticasone (Flonase)
Potential Nursing Diagnoses
Assessment
 Injury, Risk for related to adverse
Prior to administration
effects of medication
 Obtain complete health history
 Knowledge, Deficient related to drug
including allergies, drug history and
action and side effects
possible drug interactions
 Assess for presence or history of
seasonal allergic rhinitis
 Obtain vital signs
Planning: Patient Goals and Expected Outcomes
The patient will:








Remain free of physical injury
Demonstrate understanding of drug therapy
Demonstrate ability to adminster medication appropriately
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Monitor respiratory function. (Drug
 Instruct patient to immediately report signs
worsens respiratory failure, asthma attacks.)
of respiratory distress to the health care
provider.
Monitor for concurrent use of systemic
 Instruct patient to completely disclose all
corticosteroids. (Can lead to suppression of
other medications he/she is taking.
adrenal function.)
Monitor for signs of infections. (Use with
 Instruct patient to report signs of infection
caution in patients with: tuberculosis,
to the health care provider.
untreated fungal, bacterial or viral
infections due to possible development of
superinfection; ocular herpes simplex due
to worsening of symptoms due to immune
suppression.)
Monitor for signs and symptoms of
 Advise patient to inform health care
hypercorticism such as acne and
provider if any weight gain, severe skin
hyperpigmentation (due to adrenal
conditions occur, hyperactivity.
insufficiency).
Instruct patient:
Provide humidification (to decrease
crusting and drying of nasal passages).
 To report irritation of nasal passages to
health care provider
 To wash cap and nosepiece with warm
water after each use
 That transient burning of the nasal
passages as well as sneezing are common
side effects

Instruct patient:
 In proper technique for use of nasal inhaler
 To shake inhaler prior to use
 That medication will be most effective if
nasal passages are clear before use
 To use only prescribed amount to avoid
systemic side effects
 That this medication does not provide
immediate symptom relief
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming the patient goals and expected outcomes
have been met (see “Planning”).
Observe for proper use of medication.
Nursing Process Focus
Patients Receiving Oxymetazoline (Afrin)
Potential Nursing Diagnoses
Assessment
 Injury, Risk for (nosebleed) related to
Prior to administration:
adverse effects of medication
 Obtain complete health history
 Tissue Perfusion, Risk for Ineffective
including allergies, drug history and
related to adverse effects of
possible drug interactions
medication
 Assess for presence or history of nasal
 Knowledge, Deficient related to drug
congestion due to allergic conditions,
action, side effects, and administration
nasal surgery, middle ear infections
(treatment and prevention)
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate an ability to use a nasal inhaler.
 Remain free of physical injury
 Maintain effective tissue perfusion
 Demonstrate knowledge of drug therapy
Implementation



Interventions and (Rationales)
Evaluate pupil size and respiratory status
before administration. (Drug stimulates
alpha1-adrenergic receptors that may
cause constricted pupils and respiratory
depression.)
Obtain history of diabetes mellitus (Use
cautiously in these patients due to possible
interaction of drug with glucose-lower
agents.)
Monitor compliance with medication
regimen. (Rebound congestion will occur
if medication is used for longer than 5
days due to prolonged use, patient must
use more and larger doses of drug.)
Patient Education/Discharge Planning
Inform patient:
 That pupil constriction and respiratory
depression may occur
 To immediately report respiratory distress
to the health care provider
Instruct patient:
 To monitor their glucose levels frequently
when on this medication
 To notify their health care provider for
any abnormalities in their results.
 May need increased doses of glucoselowering agents
Instruct patient:
 Not to use medication longer than 5 days.
 To notify health care provider if rebound
congestion occurs
 In proper technique for administering nose
drops
 To wash hands before and after using nose
drops
 To rinse dropper in hot water after each
use


Obtain history hyperthyroidism (Use
cautiously in patients with
hyperthyroidism due to central nervous
system stimulation by drug’s effect that
possibility would cause an exacerbation of
the disease process.)
Monitor vital signs, especially pulse and
respiration. (Drug has cardiovascular
effects by stimulation of alpha1adrenergic receptors.)

Instruct patient to report nervousness,
shaking, tremors, fever, rapid heart beat
and breathing to the health care provider.
Advise patient to:
 Use only the prescribed amount
 Monitor blood pressure at same time daily
and record.
 Report any abnormal results 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 Epinephrine (Adrenalin)
Potential Nursing Diagnoses
Assessment
 Tissue perfusion, Risk for Ineffective
Prior to administration:
related to cardiovascular effects of
 Obtain complete health history
medication
including allergies, drug history and
 Sleep pattern, Disturbed, related to
possible drug interactions
CNS effects of medication
 Assess for presence/history of
 Nutrition Impaired: less than body
Anaphylactic shock, asthma,
requirements related to anorexia
cardiopulmonary resuscitation
secondary to medication
simple glaucoma, ventricular

Knowledge Deficient, related to drug
fibrillation, croup, septic shock,
action and side effects
wheezing
 Obtain vital signs
Planning: Patient Goals and Expected Outcomes
The patient will:
 Demonstrate understanding of the risks and benefits of drug therapy.
 Maintain adequate tissue perfusion
 Maintain adequate sleep
 Demonstrate maintenance of weight within normal range
Implementation





Interventions and (Rationales)
Monitor vital signs and lung sounds,
including croup and wheezing (to determine
effectiveness of drug therapy).
Patient Education/Discharge Planning
 Instruct patient to report changes in
respiratory status to the health care
provider.
Monitor blood glucose. (Use with caution in
patients with diabetes mellitus due to
epinephrine’s effect of increasing
hyperglycemia.)
Obtain history of closed angle glaucoma.
(Drug dilates the pupil, which may lead to
worsening of condition.)
Use with caution in patients with
hyperthyroidism (due to exacerbation of
thyroid crisis).

Advise patient to monitor blood glucose
frequently during treatment.

Monitoring cardiovascular status (Cardiac
arrhythmias may occur and may lead to
ventricular fibrillation. Hypertensive crisis
may occur.)

Instruct patient to immediately report
vision changes to the health care
provider.
Instruct the patient to notify the health
care provider if they experience;
increased heart rate, fever, nervousness,
tremors.
Advise patient that cardiac monitoring
will occur while receiving this
medication.


Monitor neurological status. (Drug may
cause cerebral hemorrhage.)

Instruct patient to immediately report
the first signs of severe headache.
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 Celecoxib
Potential Nursing Diagnoses
Assessment
 Injury, Risk for (Gastrointestinal
Prior to administration:
bleeding) related to adverse effects of
 Obtain complete health history including
the medication
allergies, drug history and possible drug
 Mobility, Impaired physical related to
interactions.
joint disease
 Assess for presence/history
 Knowledge Deficient, related to drug
 Rheumatoid arthritis
action and side effects
 Osteoarthritis
 Congestive heart failure
 Hypertension
 Renal disease
 Pregnancy
 assess renal function tests, e.g. BUN,
creatinine levels
Planning: Patient Goals and Expected Outcomes
The patient will:
 Avoid evidence of gastrointestinal bleeding
 Demonstrate compliance with lifestyle modifications necessary for successful medication
therapy.
 Demonstrate knowledge of drug action and side effects of drug
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Advise patient to:
 Monitor for congestive heart failure, fluid
retention, hypertension, and renal disease.
 Report any difficulty breathing to the
(Use cautiously in these patients, as drug
health care provider immediately
may cause increased edema and fluid
 Report to the health care provider
retention.)
immediately, any blood in the stool, any
swelling or skin rash or any yellow
 Monitor vital signs (especially pulse and
blood pressure) for baseline information
coloration to the eyes or skin
and to monitor the drug’s possible effect of
COX 1 inhibition on renal vasodilation.
 Monitor intake and output (due to possible
 Instruct patient to report changes in urinary
drug interactions that may decrease
output to the health care provider.
function of reabsorption of water at the loop
of Henle).

Monitor for gastrointestinal distress such as
 Advise patient to take medication with
nausea, diarrhea, abdominal pain, or
food if gastrointestinal distress is a
flatulence.
problem.
 Monitor liver function, complete blood
 Instruct patient to keep all appointments for
count, BUN, serum creatinine, and serum
laboratory tests.
electrolytes.
 Monitor lithium levels in patients who are
 Encourage patients to comply with lithium
taking lithium. (Celecoxib may alter
serum levels lab tests as ordered by health
established lithium levels.)
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”).