NURSING Process FOCUS: Patients Receiving Cyclobenzaprine (Cycloflex, Flexeril)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Pain related to disease process
 Assess for pain, muscle stiffness, and
 Impaired Physical Mobility related to
mobility (initially and throughout therapy)
pain
 Obtain complete medical history,
 Knowledge Deficit related to action and
especially renal, liver, neurological
effects of medication
diseases including blood studies:
CBC, WBC with differential for blood
dyscrasias and liver function studies
 Obtain patient’s drug history to determine
possible drug interactions and allergies
Planning: Patient Goals and Expected Outcomes
The patient will:
 State relief of pain and spasms
 Report an increase in range of motion of affected body part
 State expected outcomes of drug therapy and list reportable side effects
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct the patient to:
 Observe for side effects such as
drowsiness, dry mouth, dizziness, nausea,
 Not drive or operate dangerous machinery
vomiting, faintness, headache,
when taking muscle relaxants.
nervousness, diplopia, and urinary
 Take medication with food to decrease
retention.
gastrointestinal upset.
 Report signs of urinary retention such as
feeling of fullness, distended abdomen,
and discomfort.
 Use frequent mouth rinses and sugarless
candy or gum if expereincing dry mouth
 Monitor serum liver enzymes levels.
 Instruct patient concerning the importance
Report elevation (Medication may cause
of having lab work done
serious liver damage)
 Monitor length of time on drug. (Drug
 Inform the patient that the muscle
should be tapered to avoid rebound
relaxants should not be taken for more
spasms.)
than 3 weeks and should not be abruptly
stopped.
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 Dantrolene Sodium (Dantrium)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Pain related to disease process
 Assess for pain, muscle strength, and
 Impaired Physical Mobility related to
spasticity (initially and throughout
pain
therapy)
 Self Care Deficit related to Immobility
 Obtain complete medical history,
and pain
especially cardiac, renal, liver,
 Knowledge Deficit related to action
neurological diseases including blood
and effects of medication
studies: CBC, WBC with differential for
blood dyscrasias and liver function
studies
 Obtain patient’s drug history to determine
possible drug interactions and allergies
 Assess ability to self administer
medication
Planning: Patient Goals and Expected Outcomes
The patient will:
 State relief of pain and spasticity
 Report an increase in range of motion and dexterity of affected body part
 State expected outcomes of drug therapy and list reportable side effects
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
Instruct the patient to:
 Observe for side effects such as muscle
weakness, drowsiness, dry mouth, dizziness,
 Report side effects.
nausea, diarrhea, tachycardia, erratic blood
 Not drive or operate dangerous
pressure, photosensitivity, and urinary
machinery when taking muscle
retention.
relaxants.
 Take medication with food to decrease
gastrointestinal upset.
 Report signs of urinary retention such
as feeling of fullness, distended
abdomen, and discomfort.
 Use frequent mouth rinses, sips of
water, and sugarless candy or gum may
help with dry mouth
 Use sunscreen
 Monitor for muscle rigidity, pain, range of
 Inform patient to report changes in
motion, and dexterity (to monitor
spasticity, range of motion, dexterity,
effectiveness of medication).
and pain levels to order to determine
effectiveness.
 Monitor serum liver enzymes levels. Report
 Instruct patient concerning the
elevation.
importance of having lab work done
because medication may cause serious
liver damage.

Monitor length of time on drug. (Drug
 Inform the patient that the muscle
should be tapered over a one to two week
relaxants should not be abruptly
period to avoid rebound spasms.)
stopped.
 Monitor ability to take medication, assist if
 Instruct family or caregiver about
necessary. (Spasms may inhibit ability of
medication and proper administration in
patient to self-administer medication)
case patient is unable to self-medicate.
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 CALCIUM SUPPLEMENTS
ASSESSMENT
POTENTIAL NURSING DIAGNOSES
■
Prior to administration:
■
Obtain complete health history including
allergies, drug history, and possible drug
Risk for Injury, related to loss of bone mass and
side effects of drug
■
Deficient Knowledge, related to drug therapy
interactions.
■
■
Obtain baseline ECG.
Obtain baseline vital signs, especially apical
pulse for rate and rhythm, and blood pressure.
■
Obtain lab work to include CBC and
electrolytes, especially calcium.
PLANNING: PATIENT GOALS AND EXPECTED OUTCOMES
The patient will:
■
■
Have normal serum calcium levels (8.5–11.5 mg/dl)
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
■
Immediately report side effects and adverse reactions
IMPLEMENTATION
Interventions and (Rationales)
Patient Education/Discharge Planning
■
■
Monitor electrolytes throughout therapy.
Teach patient of importance of routine lab studies,
(Calcium and phosphorus levels tend to vary
so deviations from normal can be corrected
inversely. Low magnesium levels tend to
immediately.
coexist with low calcium levels.)
■
Monitor for signs and symptoms of
■
Instruct patient to report signs or symptoms of
hypercalcemia. (Overtreatment may lead to
hypercalcemia: drowsiness, lethargy, weakness,
excessive serum calcium levels.)
headache, anorexia, nausea and vomiting,
increased urination, and thirst.
■
■
Initiate seizure precautions for patients at risk
■
Teach patient to be aware of signs of
for hypocalcemia. (Low calcium levels may
hypocalcemia, such as seizures, muscle spasms,
cause seizures.)
facial twitching, and paresthesias.
Monitor for musculoskeletal difficulties.
(Calcium gluconate is used to treat osteoporosis,
Instruct patient to:
■
■
rickets, osteomalacia.)
Take special precautions to prevent fractures
Report episodes of sudden pain, joints out of
alignment, inability of patient to assume normal
positioning
■
Monitor intake and output. Use cautiously in
■
patient with renal insufficiency. (Calcium is
Instruct patient to report any difficulty in urination
and measure I&O.
excreted by the kidneys.)
■
Monitor cardiac functioning. (Possible side
■
effects may include short QT wave, heart block,
Inform patient to recognize and report palpitations
or shortness of breath to healthcare provider.
hypotension, dysrhythmia, or cardiac arrest with
IV administration.)
■
Monitor injection site during intravenous
■
Instruct patient to report any pain at IV site.
administration for infiltration. (Extravasation
may lead to necrosis.)
■
Monitor diet. (Consuming calcium-rich foods
may increase effect of drug. Consuming foods
■
Advise patient to: consume calcium-rich foods and
avoid zinc-rich foods
rich in zinc may decrease calcium absorption.)
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 CALCITRIOL (Rocaltrol, Calcijex)
Assessment
Potential Nursing Diagnoses
Prior to administration:




Comfort, impaired, related to effects of
calcitriol
Knowledge, deficient, related to no
previous contact with calcitriol
Therapeutic regimen management,
ineffective related to length of time
treatment is necessary
Urinary elimination, modified, urinary
frequency, related to effects of
medication
Obtain complete health history

including allergies, drug history and
possible drug interactions

Assess for presence/history of
hypercalcemia, hypocalcemia, vitamin
D toxicity, parathyroid dysfunction,

decreased renal function.
Assess lab values of electrolytes,
cholesterol, alkaline phosphatase,
calcium and creatinine
Planning: Patient Goals and Expected Outcomes
Patient will:





Demonstrate increased bone mass
Demonstrate knowledge of dietary modifications to include adequate calcium and
Vitamin D
Demonstrate understanding of drug treatment regimen
Remain free of physical discomfort
Maintain urinary elimination within normal limits
Implementation
Interventions and (Rationales)
Patient Education/Discharge Planning
*Evaluate patient knowledge about proper
storage. (Improper storage will render
calcitriol ineffective.)
*Instruct patient to protect medication from
light, heat and moisture.
*Monitor diet for adequate calcium and
phosphate content. (Effectiveness of
calcitriol therapy depends on adequate
daily intake of calcium and phosphate.)
Advise patient:
*Monitor vitamin D intake. (Excessive
intake of vitamin D may lead to
hypercalcemia.)

to include foods high in calcium and
phosphate
 to avoid foods high in sodium or
potassium
 to increase fluids, unless advised not to
by health care provider
 symptoms of hypercalcemia, deep bone
and flank pain, anorexia, nausea and
vomiting, unusual thirst, constipation,
lethargy, psychosis
*Advise patient to avoid any other sources
of vitamin D therapy while taking
calcitriol.
*Monitor for side effects/adverse reactions. *Instruct patient and caregiver to monitor
for and report: headache, weakness,
irritability, somnolence, conjunctivitis,
photophobia, rhinorrhea, anorexia,
nausea/vomiting, constipation, weight loss,
polydipsia, dry mouth, metallic taste,
polyuria, nocturia, bone and muscle pain,
pruritis, decreased libido.
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 RALOXIFENE (Evista)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Comfort, impaired, related to side
effects of raloxifene
 Obtain complete health history
including allergies, drug therapy and
 Fluid volume, excess, related to
possible drug interactions
water and sodium retention
secondary to medication
 Assess for presence, history of
pregnancy, venous thrombosis,
 Knowledge, deficient, related to no
pulmonary emboli, hnormone use,
previous contact with
breast abnormalities
medication
 Obtain vital signs
 Nausea, related to side effects of
raloxifene
 Obtain history of cardiovascular or
cerebrovascular disease
 Thought processes, disturbed,
depression, related to side effects of
medication
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate bone density within normal limits
 Demonstrate understanding of need for long-term compliance with medication
regime
 Demonstrate understanding of side effects/adverse reactions to report to health
care provider
 Maintain intact thought processes and absence of symptoms of depression
Implementation
Interventions and (Rationales)
*Monitor bone density tests and liver
function tests.
Patient Education/Discharge Planning
*Instruct patient to have bone density tests
and liver function tests prior to beginning
raloxifene and periodically during therapy.
*Monitor for thromboembolism. (This may *Advise patient about symptoms to report
indicate need to discontinue therapy.)
immediately: pain in calf; sudden dyspnea
accompanied by feeling of breathlessness
and impending doom; vision changes.
*Monitor weight. (Edema may appear, and Teach patient and caregivers:
cause weight gain.)
 how to perform accurate weights
 to report weekly weight gain >5 lbs
*Monitor activity level. (Prolonged periods Advise patient:
of immobility may increase risk of
 to avoid sitting in one position for long
thromboembolism.)
period
 to increase exercise if able and to do
weight-bearing exercises, or to use
weights when exercising
*Obtain smoking history. (Smoking has an Encourage patient:
inverse effect on bone density.)
 to stop smoking

to attend smoking-cessation clinics,
courses, etc.
*Monitor for hot flashes. (Raloxifene does Teach patient:
not prevent, and may induce, hot flashes.)
 that raloxifene does not help decrease
severity of hot flashes
 measures that may increase comfort:
dressing in layers, explaining
physiology of hot flashes, drinking cool
liquids, keeping thermostats turned
lower than normal, etc.
*Monitor for GU complaints. Patient may
*Advise patient to increase fluid intake,
experience breast pain, vaginal burning, or drink cranberry juice, practice careful
itching, UTI. (Raloxifene exhibits selective personal hygiene, wear a supportive bra.
estrogen receptor antagonist activity on
breast and uterus.)
*Monitor diet for calcium content. (It may *Advise patient to consume foods with
be recommended that patient take a
high calcium content, especially milk and
calcium supplement if diet is low in
milk products, and leafy green vegetables.
calcium.)
Evaluation of Outcome Criteria
Evalaute the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
NURSING PROCESS FOCUS: Patients Receiving Etidronate (Didronel)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Knowledge, deficient, related to no
prior exposure
 Obtain complete health history
including allergies, drug history and
 Fluid volume, imbalanced, risk for,
possible drug interactions
related to adverse reaction to
medication
 Assess for presence/history of
pathologic fractures, hypocalcemia,
 Nausea, related to side effects of
hypercalcemia
medication
 Assess nutritional status
 Pain, acute, bone, related to adverse
reaction to etidronate
 Obtain lab work to include complete
blood count, pH, electrolytes and renal
 Therapeutic regimen management,
function studies (BUN, creatinine, uric
ineffective, related to fact that
acid)
therapeutic response may take 1-3
months
 Assess lab values of calcium and
phosphorous
Planning: Patient Goals and Expected Outcomes
Patient will:
 Demonstrate decreased progression of osteoporosis or Paget’s disease
 Demonstrate decreased risk for pathologic fractures
 Remain free of side effects or adverse reactions
 Demonstrate understanding of dietary needs/modifications
 Maintain adequate fluid volume
Implementation
Interventions and (Rationales)
*Monitor for pathologic fractures and bone
pain. (Etidronate causes defective
mineralization of newly formed bone.)
Patient Education/Discharge Planning
*Instruct patient and caregiver to report any
sudden bone or joint pain, inability of
patient to correctly position self, swelling
over bone or joint.
*Monitor for GI problems. (There may be
*Advise patient and caregiver that new
problems with etidronate absorption if
onset nausea or diarrhea may be symptom
patient has persistent nausea or diarrhea.)
of adverse reaction, and to report
immediately.
*Monitor serum calcium lab values:
Advise patient:
Serum calcium levels should be 9-10mg/dl.  to have lab studies performed prior to
(Through its inhibition of bone resorption,
beginning etidronate therapy and
etidronate causes blood levels of calcium
periodically during therapy
to fall.)
 symptoms of hypocalcemia to report
(muscle spasms, facial grimacing,
convulsions, irritability, depression,
psychoses)
 symptoms of hypercalcemia to report
(increased bone pain, anorexia,
nausea/vomiting, constipation, thirst,
lethargy, fatigue, confusion, depression)
*Monitor kidney function, especially
creatinine. (Etidronate cannot be used in
patients whose creatinine is >5.)
*Monitor BUN, vitamin D, urinalysis,
phosphate, magnesium levels.
*Monitor for side effects/adverse reactions
including new onset nausea or diarrhea,
metallic taste, constipation, stomatitis,
fluid overload, chest pain, dyspnea,
seizures.
*Monitor dietary habits. (Diet must have
adequate amounts of vitamin D, calcium
and phosphates.)
*Instruct patient and caregiver to report any
urinary changes, such as decreased urine
production, increased urination.
*Instruct patient what symptoms to be
aware of, and to report onset of them
immediately.
*Advise patient to include good food
sources of vitamin D, calcium and
phosphates, including dairy products and
green leafy vegetables.
*Monitor compliance with recommended
Advise patient:
regime.
o that therapy should continue for 6
months maximum, but full therapeutic
response may take 1-3 months
o that effects continue several months
after drug is discontinued
o to avoid vitamins, mineral supplements,
antacids and high-calcium products
within 2 hours of taking etidronate. (All
bisphosphonates are poorly absorbed
from the GI tract. Measures should be
taken to maximize absorption.)
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected
outcome have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving HYDROXYCHLOROQUINE SULFATE (Plaquinil Sulfate)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Fluid volume, deficient, related to
diarrhea, anorexia, nausea, vomiting
 Obtain complete health history
including allergies, drug history and
secondary to medication
possible drug interactions
 Knowledge, deficient, related to no
previous contact with this
 Assess for presence/history of
malaria, rheumatoid arthritis, lupus
medication
erythematosus
 Nutrition, imbalanced, less than
 Assess mental status
body requirements, related to
anorexia, nausea, vomiting, diarrhea
 Assess GI status
secondary to medication
 Assess CBC, platelets, liver function
 Sensory perception, disturbed,
tests, vision and hearing tests G6PD
vision and/or hearing, related to
deficiency, muscle strength, reflexes,
adverse reactions of medications
EKG (depressed T waves, widening
of QRS complex)
Planning: Patient Goals and Expected Outcomes
Patient will:
 experience no symptoms of malarial infection,
 decreased symptoms of rheumatoid arthritis with increased joint mobility,
 decreased symptoms of lupus erythematosus
 Demonstrate understanding of necessity of taking hydroxychloroquine exactly as
ordered
 Recognize side effects and need to report
 Demonstrate understanding of necessity of follow-up appointments
Implementation
Interventions and (Rationales)
*Monitor for hepatic problems, actual or
potential. (Administer medication with
caution to patients with decreased liver
function, any patient taking hepatotoxic
drugs, or alcoholic patient.)
*Monitor patient and family knowledge
regarding expected effects of medication.
*Monitor for symptoms of toxicity.
Patient Education/Discharge Planning
*Instruct patient to report symptoms of
liver dysfunction to health care provider.
Advise patient and caregiver:


that urine may turn rust or brown
to wear sunglasses outside to decrease
photo-phobia
 to report symptoms of blood dyscrasias
(fever, fatigue, bruising, unusual
bleeding
*Instruct patient to discontinue drug and
report to health care provider immediately
if any of following occur: blurred vision
and difficulty focusing, headache,
dizziness, urticaria.
Evaluation of Outcome Criteria
Evalautge the effectiveness of drug therapy by confirming that patient goals and expected
outcomes have been met (see “Planning”).
NURSING PROCESS FOCUS: Patients Receiving Colchicine
ASSESSMENT
POTENTIAL NURSING DIAGNOSES
Prior to administration:
■
■
Obtain complete health history including allergies,
■
drug history, and possible drug interactions.
■
■
■
Obtain baseline vital signs.
Activity Intolerance, related to joint pain
Disturbed Body Image, related to joint swelling
Deficient Knowledge, related to effects and side
effects of drug therapy
Obtain lab work to include CBC, platelets, uric
acid levels, renal and liver function tests, and
urinalysis.
PLANNING: PATIENT GOALS AND EXPECTED OUTCOMES
The patient will:
■
■
Report a decrease in pain and an increase in function in affected joints
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
■
Immediately report side effects and adverse reactions
IMPLEMENTATION
Interventions and (Rationales)
Patient Education/Discharge Planning
■
■
Monitor lab results throughout therapy.
Teach patient importance of routine lab studies,
(Agranulocytosis and thrombocytopenia may
so deviations from normal can be corrected
occur.) Perform Coombs test for hemolytic
immediately.
anemia.
■
Monitor for signs of toxicity.
■
Instruct patient to report weakness, abdominal
pain, nausea, and/or diarrhea.
■
Monitor for signs of renal impairment such as
oliguria. Record intake and output.
■
Instruct patient to report a decrease in urinary
output and to increase fluid intake to 3–4 L/day.
■
Ensure that medication is administered correctly.
■
Inform patient to take medication on an empty
stomach. Medication should be taken at first sign
of gout attack.
■
Monitor for pain and mobility. (This is used to
assess effectiveness of medication.)
■
Teach patient to report an increase or decrease in
discomfort and swelling.
EVALUATION OF OUTCOME CRITERIA
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have
been met (see “Planning”).