Nursing Process Focus:
Patients Receiving Salmeterol (Serevent)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Impaired gas exchange related to
bronchospasm
 Assess for presence/history chronic
asthma, exercise induced asthma, acute
 Risk for altered heart rhythm related to
asthma attacks and acute upper airway
side effects of medication
obstruction
 Injury, Risk for related to tremors
 Assess respiratory rate and lung sounds,
secondary to side effects of medication
pulse blood pressure, EKG, and liver
function
 Obtain EKG and complete blood
studies: CBC, chemisty panel, and liver
function studies.
 Assess patient’s drug history to
determine possible drug interactions and
allergies.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Immediately report worsening asthma, irregular heart beat, and severe headache.
 Be compliant with required laboratory test.
 Demonstrate ability to use a metered dose inhaler
Implementation
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Interventions and (Rationales)
Monitor for occurrences of acute asthma
attacks. (This medication is contraindicated
in patients with acute asthma attach,
worsening or deteriorating asthma and
acute upper airway obstruction. May cause
worsening of acute asthma and
bronchospasm.)
Evaluate patient’s ability to use inhaler
Monitor EKG and electrolyte values.
(Increased risk of hypokalemia and EKG
abnormalities if medication is combined
with diuretics.)
Monitor neurological status. (Tremors of
the hand are a common side effect.)
Monitor for side effects including
Patient Education/Discharge Planning
 Instruct patient to notify health care
provider immediately if there are any
changes in respiratory status
 Ensure that patient is aware that this
medication is not to be used for an acute
asthma attack.
Instruct patient
 In proper use of metered dose inhaler; not
use more than 4 puffs/day or risk an
increase in asthma symptoms
 To use medication 30 to 60 minutes prior
to activity if used to treat exercise induced
asthma
 Instruct patient of the need for regular
EKG and electrolyte laboratory tests if the
patient also takes a diuretic.
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Instruct patient to use care when operating
machinery because of hand tremors.
Instruct patient of signs of side effects and
headache, tachycardia, palpitations,
hypertension, anxiety, nervousness and
restlessnessa, bronchospasms, dry nose and
mouth.
to notify health care provider of
symptoms of side effects
 Inform patient to use sips of water for sore
throat or saline nasal sprays for irritated
nasal passages.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expecte4d
outcomes have been met (see “Planning”).
Nursing Process Focus:
Patients Receiving Beclomethasone (Beconase)
Assessment
Potential Nursing Diagnoses
Prior to administration:
 Obtain complete health history including
 Injury, Risk for related to infection
allergies, drug history, and possible drug
secondary to corticosteroid effects of
interactions
medication
 Assess for presence/history of asthma,
 Knowledge, Deficient related to drug
seasonal rhinitis, hypertension, congestive
action and side effects
heart disease, and blood clots.
 Risk for impaired gas exchange related to
 Initially and throughout treatments, assess
bronchospasm
temperature, weight, acute asthma attack,
and presence of infection.
Planning: Patient Goals and Expected Outcomes
The patient will:
 Immediately report sore throat, fever, “Moon” face, bruising, weight gain and
wheezing.
 Demonstrate understanding of use of aerosol inhaler or nasal spray
 Comply with all laboratory tests needed to monitor medication effectiveness.
 Maintain effective respiratory function
 Demonstrate knowledge of drug therapy
Implementation
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Interventions and (Rationales)
Evaluate lung sounds and respiratory rate.
(Do not use if patient is experiencing an
acute asthma attack.)
Monitor for usual signs and symptoms of
infection may not be evident. (Drug may
interfere with normal immune response.)
Use cautiously in patients with
hypertension, gastrointestinal disease,
congestive heart failure and blood clots.
Monitor integrity of oral mucosa. (May
cause fungal infection of mouth and
throat.)
Evaluate use of aerosol inhaler to
administer medication.
Monitor for side effects of medication
including sore throat, fever, moon face,
bruising, weight gain, and wheezing.
Patient Education/Discharge Planning
 Advise patient that medication should not
be used during an acute asthma attack.
Instruct patient to:
 Monitor temperature daily.
 Avoid crowds and people with active
infection
 Instruct patient to notify health care
provider of any tarry stools, edema,
dizziness and difficulty breathing.
 Instruct patient to report to health care
provider the first sign of a sore throat.
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Instruct patient in the proper use of
aerosol inhaler and nasal spray.
Inform patient of signs and symptoms of
side effects and to report side effects to
health care provider
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Instruct patient to:
 Monitor blood sugar closely
 Report blood sugar elevations 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”).
Monitor blood glucose levels. (Glucose
tolerance may be affected by use of drug.)