Nursing Process Focus:Patients Receiving Ethinyl Estradiol With Norethindrone (Ortho-Novum)

AssessmentPrior to administration: Obtain complete health history

including allergies, drug history and possible drug interactions

Assess for presence/history of pregnancy, thrombophlebitis, CVA, breast cancer

Obtain history of smoking Obtain vital signs

Potential Nursing Diagnosis Anxiety, related to concern about

medication failure with resultant pregnancy, imbalances in hormones

Comfort, impaired, related to side effects of medication

Health maintenance, ineffective, related to lack of knowledge or understanding of positive health practices (smoking cessation, etc.)

Knowledge, deficient, related to no prior contact with oral contraceptives

Nutrition, imbalanced, either less than or more than body requirements, related to imbalance in hormone make-up of oral contraception

Planning: Patient Goals and Expected Outcomes

Patient will:

Demonstrate compliance with medication regimen Avoid pregnancy Remain free of side effects Demonstrate knowledge of drug therapy and potential side effects

ImplementationInterventions and (Rationales) Patient Education/Discharge Planning

Monitor for pregnancy. (Medication must not be administered to woman who is pregnant. Medication is teratogenic.)

Teach patient: That she must have had negative pregnancy

test within 2 weeks prior to beginning medication

To immediately have pregnancy test if pregnancy is suspected during therapy

Monitor for breast or other estrogen-dependent tumors. (Estrogen in medication may cause tumor growth or proliferation.)

Teach patient to: Give full medical and family medical history

prior to beginning therapy Report to health care provider immediately if

1st degree relative is diagnosed with any estrogen-dependent tumor

Observe for thrombophlebitis or other thromboembolic disease. (Estrogen-containing medications predispose a woman to thromboembolism.)

Advise patient of signs of possible thromboembolic event, and to immediately report: pain in calves, limited movement in legs, dyspnea, sudden severe chest pain, anxiety, fear.

Monitor for cardiac disorders. Advise patient of signs of possible cardiac

(Medication will lead to worsening of cardiac problems.)

problems which must be immediately reported: chest pain, dyspnea, edema, tachycardia or bradycardia, palpitations.

Monitor for cerebrovascular disorders. (Medication increases risk for thrombotic disorders, one of leading causes of CVA.)

Teach patient: To contact all health care providers prior to

starting oral contraception so other medications can be adjusted as needed

Signs of impending migraine headache or seizure, so preventative measures can be taken

Obtain history of cigarette smoking. (Combination of oral contraception and smoking greatly increases risk of cardiovascular disease, especially MI Risk increases with age >35 and with number of cigarettes smoked, e.g., 15 or more/day.)

Advise patient to: Stop smoking prior to beginning treatment

with oral contraceptives Attend smoking cessation groups.

Monitor mental status. (Side effects such as weight gain may cause depression in some women.)

Instruct patient regarding symptoms of depression to report immediately: lack of interest in every-day activities, changes in sleeping or eating habits, stopping previously enjoyable activities, etc.

Monitor blood glucose in patients with diabetes. Use with caution in woman with diabetes or with familial history of diabetes. (Combination may upset glycemic control so patient would experience either hypo- or hyper-glycemia; adjustments in dose of hypoglycemic medications may be necessary.)

Advise patient to monitor urine and blood glucose regularly, and contact health care provider if any abnormalities occur so adjustments in hypoglycemic medication can be made.

Monitor for side effects or adverse reactions. (If serious side effects occur, patient may need to switch to oral contraceptive with a different combination or percentage of hormones.)

Advise patient to: Be aware of edema, unexplained loss of

vision, diplopia, intolerance to contact lens, nausea, gall bladder disease, diarrhea or constipation, abdominal cramps, changes in urinary function, dysmenorrhea, breast fullness, fatigue, skin rash, acne

Note mid-cycle breakthrough bleeding, vaginal candidiasis, photosensitivity, changes in urinary patterns, feelings of abdominal fullness

Monitor whether patient understands how/when to take medication. (Only with thorough understanding will she be able to take medication correctly and avoid adverse reactions, or be aware of physical changes that could be secondary to the medication, and take measures to prevent permanent, serious harm.)

Advise patient to: Use barrier contraceptive during 1st week of

initial cycle and for 7 days after 2 consecutive missed doses

Discontinue medication and notify health care provider if bleeding resembling menstrual cycle occurs mid-cycle

Be aware of fluid retention (teach to weigh self weekly and record, note tightening of rings, shoes, etc.)

Decrease salt intake if edema occurs Contact health care provider if 2 consecutive

periods are missed; pregnancy may have occurred

Follow recommendations for follow-up Do self breast exams monthly Have annual PAP smears done. See health care provider at regular intervals

Evaluation of Outcome CriteriaEvaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Conjugated Estgrogens (Premarin) and Conjugated Estrogens with

Medroxyprogesterone (Prempro)ASSESSMENTPrior to administration: Obtain complete health history including

allergies, drug history and possible drug intgeractions

Assess for presence/history of breast cancer, estrogen dependent cancer, abnormal genital bleeding, thromboembolic disorders, cardiovascular disorders, smoking history, pregnancy

POTENTIAL NURSING DIAGNOSES Body image, disturbed, related to side

effects of medication Comfort, impaired, related to effects of

medication Fluid volume, excess, related to edema

secondary to medication Noncompliance, related to unpleasant

side effects, desire for pregnancy, lack of knowledge or understanding of proper self-administration

Tissue perfusion, impaired, cardiopulmonary, related to development of thrombophlebitis, pulmonary embolism, or cerebral, related to incidence of CVA secondary to medication

PLANNING: PATIENT GOALS AND EXPECTED OUTCOMESPatient will: Demonstrate understanding of correct self administration and potential side effects Demonstrate positive body image and self-concept Remain compliance with drug regimen Remain free of symptoms of thrombophlebitis or other clot development

Implementation Interventions and (Rationales) Patient Teaching/Discharge Planning Obtain history of cancer in patient or close

relative. (Estrogen-dependent cancer combination of medication and estrogen-dependent tumors, either currently or history of, put patient at much higher risk for developing cancer.)

Advise patient of importance of complete physical exam prior to beginning therapy with conjugated estrogen.

Monitor for signs of pregnancy. (Can cause serious fetal harm.)

Instruct patient to Have negative pregnancy test no more than

2 weeks prior to beginning conjugated estrogen therapy and periodically during treatment

Report immediately if she suspects she is pregnant

Monitor for current or past history of thromboembolism. (Estrogen use increases chance of thromboembolism occurring.)

Advise patient of importance of complete disclosure of past medical history.

Monitor for undiagnosed abnormal uterine Instruct patient to have complete physical

bleeding. (Can increase bleeding, tumor size, if undiagnosed tumor present.)

exam prior to beginning therapy.

Monitor for cardiovascular/cerebrovascular disorders. (Must be used with caution in patients with CAD, hypertension, and cerebrovascular disease. Any of these conditions predispose woman to thromboembolic disorders. Cardiovascular side effects are the most serious side effects, and include MI, pulmonary embolism, hypertension, CVA.)

Teach patient to: Have complete physical exam prior to

estrogen therapy Have routine blood pressure screening;

teach that hypertension has no symptomsInform female patients that atypical symptoms of a MI may be experienced: fatigue, dyspnea, nausea, light-headedness, palpitations, “racing” heart and to report to health care provider immediately if any of these sensations occur

Evaluate breast health. (Use with caution in patient with fibrocystic breast disease, breast nodules, or abnormal mammograms. Can cause worsening of condition. If cancer develops, it is essential to have baseline information with which to make comparisons.)

Advise patient of importance of complete physical exam prior to treatment and periodically during treatment.

Monitor for vision changes. (Medication may cause worsened myopia or astigmatism, intolerance of contact lenses.)

Instruct patient to: Have complete eye exam prior to

beginning treatment and periodically during treatment

Report if decreased vision occurs, or if intolerance to contact lenses occurs

Obtain smoking history. (Smoking increases risk of cardiovascular disease, especially when in combination with estrogens.)

Instruct patient to: Quit smoking Attend smoking cessation programs

Monitor for diabetes mellitus. (Estrogens may alter blood glucose levels.)

Advise diabetic patient to monitor blood glucose frequently and report if any consistent changes.

Monitor for seizure disorder. (Estrogen-induced fluid retention may increase incidence of seizures.)

Teach patient to Disclose information if seizure disorder

present Consult health care provider of anti-seizure

medication prior to beginning estrogen therapy

Be extra alert for possibility of seizures occurring

Observe for side effects. Side effects are dose dependent, and include: weight gain, edema, nausea/vomiting, abdominal cramps and bloating, acute pancreatitis, appetite changes, skin eruptions, mental depression, decreased libido, headache,

Advise patient of common side effects and to be alert to occurrence of them.

fatigue, nervousness. Monitor for GU changes. (Can be caused

by estrogens: breakthrough bleeding, spotting, changes in amount and/or duration of menstrual flow, amenorrhea during and after use, candida vaginitis.)

Advise male patient that he may develop feminine characteristics or become impotent; teach him these will resolve when treatment completed

Advise female patient to report any of GU changes.

Evaluate patient’s understanding and proper self-administration. (To ensure patient safety)

Instruct patient: Regarding dose, form and frequency of

medication To take with food to decrease GI irritation To take daily dose at HS to decrease

occurrence of side effects That if cyclic therapy ordered, to take

medication for 3 weeks and then omit for 1 week

To document menstruation and any problems that occur

To report immediately if pregnancy suspected

To take lowest effective dose for shortest time period, to decrease chances of side effects developing

Risks associated with supplemental estrogens

Evaluation of Outcome CriteriaEvaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus:

Patients Receiving Medroxyprogesterone (Provera)AssessmentPrior to administration: Obtain complete health history including

allergies, drug history and possible drug interactions.

Assess for presence/history of: Pregnancy Dysfunctional uterine bleeding Metastatic endometrial or renal cancer Endometrial hyperplasia Thrombophlebitis or thromboembolic

disease Breast cancer Decreased liver or kidney function Depression Epilepsy Asthma Migraine headache Cardiac disorders

Potential Nursing Diagnoses Health maintenance, ineffective, related

to lack of knowledge or understanding of positive health practices, such as smoking cessation

Nausea, related to side effects of medicationNutrition, imbalanced, less than or more than body requirements related to imbalance in hormone make-up

Sexual dysfunction, relate to hormonal imbalance

Sleep pattern disturbed, insomnia, related to effects of medication

Therapeutic regimen management, ineffective, related to knowledge deficit or planned failure of therapy

PLANNING: PATIENT GOALS AND EXPECTED OUTCOMESPatient will: Follow medication regime exactly as recommended Remain free of sleep disturbances Remain free of side effects or adverse reactions Demonstrate understanding of side effects and adverse reactions to report Maintain usual sexual function Maintain nutrition at expected level Demonstrate understanding of appropriate lifestyle changes

Implementation Interventions and (Rationales) Patient Education/Discharge Planning

Monitor for pregnancy. (Medication must not be administered to woman who is pregnant; will cause serious fetal damage.)

Instruct patient that she must have negative pregnancy test within 2 weeks prior to beginning medication.

Monitor for seizure disorder. (Fluid retention secondary to medication may increase seizure activity. Use with caution in women with seizure disorders.)

Advise patient: Of importance of consulting health care

provider who ordered anticonvulsants before beginning this medication

Regarding life-style changes that may decrease chances of triggering seizure activity

Monitor for hypercalcemia. (Medication may cause increased serum calcium levels, especially if in conjunction with a low daily fluid intake.)

Advise patient to: Have regular lab studies performed Increase fluids as way to decrease chance

of hypercalcemia occurring Note signs of hypercalcemia and report

immediately: deep bone and flank pain, anorexia, nausea/vomiting, thirst, constipation, lethargy, psychoses)

Monitor mental status. (Use with caution in women with history of depression. Medication may cause nervousness, insomnia, worsening of depression.)

Advise patient and caregivers regarding symptoms of depression to note and report: changes in eating and sleeping habits, disinterest in every-day activities, failure to perform ADLs, etc.

Evaluate patient’s knowledge level. (Informed patient will comply more fully with

administration regime, and be more aware of and alert to adverse reactions.)

Instruct patient: How and when to take medication, and

importance of taking exactly as ordered if being used for contraception

Proper self-administration if being taken as cancer therapy

Regarding symptoms of hypercalcemia Monitor for side effects: amenorrhea,

nausea, jaundice, dizziness, headache, signs of pulmonary embolism (sudden severe chest pain and dyspnea), edema, weight gain. Report immediately

Instruct patient to: Monitor for side effects and to report to

health care provider if they occur Monitor for edema or weight gain by

weighing self weekly and recording; noting if rings or shoes become tight

Observe foreskin changes caused by reactions to medication.

Instruct patient: To monitor for pruritis, urticaria, acne,

rash, hirsutism, alopecia That these changes are temporary and will

improve upon discontinuation of this medication

Evaluation of Outcome CriteriaEvaluate effectiveness of drug therapy by confirming patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Oxytocin

AssessmentPrior to administration:

Obtain complete health history including complete past and present gynecological and obstetric history

Obtain drug history to determine possible drug interactions and allergies

Obtain vital signs Asses fetal monitoring

Potential Nursing Diagnosis Comfort, Impaired related to strong

uterine contractions Excessive fluid volume Injury, Risk for to fetus related to effect

of drug on uterine contractions

Planning: Patient Goals and Expected OutcomesPatient will

Demonstrate increase in force and frequency of uterine contractions and/or let down of milk for breastfeeding.

Demonstrate understanding of the drug’s action by accurately describing drug side effects and precautions.

Demonstrate need to report effects such as listlessness, headache, confusion, anuria, hypotension, nausea, vomiting, and weight gain.

ImplementationInterventions and (Rationales) Patient Education/Discharge Planning Administer IV medication through

infusion device (To maintain accurate dosing)

Inform patient regarding the need for equipment.

Monitor fetal heart rate. (Increase in force and frequency of uterine contractions may cause fetal distress.)

Instruct patient about the purpose and importance of fetal monitoring.

Monitor maternal status including BP, pulse, and frequency, duration and intensity of contractions and pain. (Initial administration of mediation may cause a drop in blood pressure. High doses may increase duration and intensity of contractions and increase pain level)

Instruct patient about the importance of monitoring maternal status.

Monitor fluid balance. (Prolonged IV infusion may cause water intoxication.)

Instruct patient to report symptoms of water intoxication including drowsiness, listlessness, headache, confusion, anuria, or weight gain.

Monitor for post partum/post abortion hemorrhage.

Instruct patient: About the importance of being monitored

frequently after delivery or after abortion To report severe vaginal bleeding or

increase in lochia

Evaluation Outcome CriteriaEvaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).

Nursing Process Focus: Patients Receiving Testosterone Base (Andro and Others)

AssessmentPrior to administration: Obtain complete health history including

allergies, drug history and possible drug interactions.

Assess for presence/history of hypogonadism, secondary sex characteristics, increased or decreased libido, low sperm count, impotence

Monitor history of cardiovascular disease

Potential Nursing Diagnosis Body image, disturbed, related to lack of

normal sexual development, impotence, decreased sperm count, growth retardation, gynecomastia,

virilism in females Coping, ineffective, related to delayed

sexual development and inability to accept this

Family processes, interrupted, related to male’s inability to function sexually and/or inability to impregnate partner

Identity, disturbed personal, related to lack of secondary sex characteristics expected in pubertal boy

Sexual dysfunction, related to lack of normal

amounts of androgenPlanning: Patient Goals and Expected Outcomes

Patient will:

Experience improvement of underlying condition for which testosterone ordered, without worsening of underlying condition, with few side effects and no adverse reactions

Demonstrate understanding of how/why he/she is taking medication and desired effects Demonstrate improved body image as effectiveness of medication is established Experience return of usual sexual function

Implementation Interventions and (Rationales) Patient Education/Discharge Planning Monitor for prostatic or male breast

cancer. (Testosterone will worsen either condition.)

Instruct patient to: Have complete medical exam including

PSA tests prior to taking testosterone and periodically during therapy

Note and report any symptoms of altered urinary function: retention, hesitancy, nocturia, hesitancy, frequency, dribbling

Monitor for serious renal disease. (Edema caused by testosterone and added stress placed on the kidneys.)

Instruct patient to: Have renal function tests, BUN, creatinine

performed prior to testosterone therapy and periodically during therapy

Report immediately any symptoms of kidney dysfunction: decreased urination, edema, uremic frost, confusion, etc.

Monitor for decreased cardiac function. (Edema caused by testosterone stresses the heart.)

Instruct patient to: Have cardiac function tests performed prior

to and periodically during therapy

Immediately report symptoms of decreased cardiac function: general weakness, fatigue, dyspnea, and edema

Monitor serum cholesterol levels. (Elevated cholesterol levels secondary to testosterone administration may increase patient’s risk of cardiovascular disease.)

Instruct patient: To have cholesterol levels measured prior to

and periodically during therapy Regarding lifestyle modifications which

may lower risk of hypercholesterolemia: low fat diet, increased exercise, decrease consumption of red meat, butter, fried foods, etc.

If patient is female, monitor for pregnancy or lactation. (Testosterone crosses into breast milk and may cause damage to infant, including masculinization of female infant.)

Instruct patient: To have negative pregnancy test within 2

weeks before initiating testosterone therapy and monthly during therapy

Regarding the importance of reliable birth control during testosterone therapy

Monitor for hypercalcemia. (Hypercalcemia in patient with metastatic breast cancer usually indicates bone metastasis.)

Instruct patient: To have lab studies performed prior to

and during therapy About symptoms of increased serum

calcium and to report immediately if the following occurs: deep bone and flank pain, anorexia, nausea/vomiting, thirst, constipation, lethargy, psychoses

Evaluate bone growth in children and adolescents. (Premature epiphyseal closing may occur, leading to growth retardation.)

Advise patient and caregivers that bone age determinations should be done every 6 months.

Monitor fluid intake. (Increased fluids will increase urine production and decrease chance of stone formation.)

Advise patient: To consume 3,000-4,000cc fluid daily That urinary output will increase, and not to

be alarmed Non-liquids that can be consumed to

increase fluid intake: gelatin, popsicles, ice cream, etc.

Monitor for diabetes mellitus. (Testosterone therapy may change glucose tolerance.)

Instruct patient to: Monitor blood sugar daily and notify health

care provider if changes occur Make needed adjustments in hypoglycemic

medications and dietEvaluation 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 Sildenafil (Viagra)AssessmentPrior to administration: Obtain complete health history

including hematologic disorders, cardiac, kidney or liver disease, and anatomic deformities

Obtain drug history, specifically organic nitrates and nitroglycerin, to determine possible drug interactions and allergies

Potential Nursing Diagnosis Body image, Disturbed related to impaired

sexual function Sexual dysfunction related to known or

unknown cause Sensory perception, disturbed, visual

related to disease process.

Planning: Patient Goals and Expected OutcomesPatient will:

Report more positive body image during drug therapy Report normal sexual function Demonstrate understanding of the drug’s action by accurately describing side effects and

precautions, and importance of follow-up careImplementation

Interventions and (Rationales) Patient Teaching/Discharge Planning Monitor cardiovascular status. (Patient

who has 1st attack of angina during time he is taking sildenafil should not receive any nitrate products.

Instruct patient and/or caregiver to: Carry identification stating he is taking

Sildenafil, so he will not be given nitrates Recognize the importance of EKG monitoring

periodically during therapy Have vital signs, including BP, checked routinely during therapy with

slidenafil Recognize CV risk factors and modify:

smoking, high fat/high cholesterol diet, lack of exercise, obesity, Type A personality, high stress lifestyle

Monitor sexual response to include:*Frequency, firmness, maintenance of erections; *Frequency of orgasms*Frequency, satisfaction and enjoyment of sexual activity;*Satisfaction with sexual relationship

Instruct patient and/or caregiver to: Keep diary R/T use of sildenafil, sexual

response, any cardiovascular symptoms that may occur

Report any changes to health care provider Seek emergency care if erection lasts longer

that 4 hours. Monitor diet. (High fat meals can

delay absorption of sildenafil and delay onset of action by 1 hour. Taking sildenafil with grapefruit juice may lead to increased serum sildenafil levels, leading to adverse effects.)

Instruct patient and/or caregiver to: Avoid administration of Sildenafil with meals,

especially high-fat meals Avoid grapefruit juice when administering

Sildenafil

Monitor patient knowledge and understanding.

Instruct patient and/or caregiver that: Sildenafil should not be taken more than once

in a 24 hour period Optimum time to take Sildenafil is 1 hour

prior to sexual activity, but that it can be taken for up to 4 hours prior

Sildenafil will not produce erection unless he is sexually stimulated

This medication should not to share medication with anyone else

Evaluation of Outcome CriteriaEvaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”).