Nursing Process Focus:
Patients Receiving Phenelzine (Nardil)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Sorrow, Chronic related to |
|Obtain complete medical history including allergies, neurological , |depressive state. |
|cardiac, renal, biliary, and mental disorders including blood |Thought Processes, Disturbed related to |
|studies: CBC, platelets and liver enzymes,. |effects of drug therapy |
|Obtain patient’s drug history to determine possible drug interactions|Adjustment, Impaired related to inadequate |
|and allergies |drug effectiveness. |
|Obtain 24 hour dietary history to identify |Knowledge, Deficient, related to drug |
|tyramine containing foods ingested |action and side effects. |
|recently |Suicide, Risk for related to inadequate drug |
|Assess neurological status, including identification of recent mood |effectiveness. |
|and behavioral patterns |Hopelessness related to emotional state. |
|Planning: Patient Goals and Expected Outcomes |
|The patient will |
|Report mood elevation and will effectively engage in activities of daily living. |
|Report an absence of suicidal ideations and improvement in thought processes. |
|Demonstrate understanding of the drug's action by accurately describing drug effects and |
|precautions. |
|Implementation |
| Interventions and (Rationales) | Patient Education/Discharge Planning |
|Monitor vital signs, especially pulse and blood pressure. |Instruct the patient to immediately report: |
|(Phenelzine may cause orthostatic hypotension.) |Any change in sensorium particularly impending syncope. |
| |Avoid abrupt changes in posture; rise slowly from prolonged periods of|
| |sitting/lying down. |
| |Monitor vital signs (especially blood pressure) ensuring proper use of |
| |home equipment. |
| |Consult the health care provider regarding "reportable" blood pressure |
| |readings (e.g. "lower than 80/50). |
|Monitor cardiovascular status. | Instruct patient to immediately report severe headache, dizziness, |
|Observe for hypertensive crisis and signs of impending stroke or |paresthesias, bradycardia, tachycardia, nausea/vomiting, diaphoresis. |
|M.I.: severe headache, dizziness, paresthesias, bradycardia, | |
|tachycardia, nausea/vomiting, diaphoresis. | |
|Monitor neurological status. |Instruct patient to report significant changes in neurological status, |
|Observe for changes in LOC and seizures. Use with caution in |such as seizures, extreme lethargy, slurred speech, disorientation or |
|epilepsy. (MAOIs may reduce the seizure threshold.) |ataxia. |
|Monitor mental and emotional status. |Interview patient regarding suicide potential; |
|Observe for suicidal ideation. Therapeutic benefits may take 2-6 |Obtain a "no-self harm" verbal contract from the patient. |
|weeks. |Instruct the patient to immediately report dysphoria or suicidal |
| |impulses. |
|Monitor kidney and liver function. |Instruct the patient to: |
|Observe for signs of hepatic toxicity. Monitor laboratory blood |Report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, |
|work such as platelets, PT, PTT, and liver enzymes. |tenderness or distention, or change in color of stool |
|Assess urinary output and edema in feet/ankles. (Medication is |Adhere to a regular schedule of laboratory testing for liver function as |
|excreted through the kidneys. Long term use may lead to renal |ordered by the health care provider. |
|dysfunction.) |Report changes in urination, flank pain or pitting edema immediately. |
|Monitor CBC, BUN, creatinine, and urinalysis. | |
|Ensure patient safety. (Dizziness caused by postural hypotension |Instruct the patient to: |
|increases the risk of fall injuries.) |Call for assistance before getting out of bed or attempting to ambulate |
|Raise bed rails. Place call bell within patient's reach. |alone. |
| |Avoid driving or other activities requiring mental alertness or physical |
| |agility until blood pressure is stabilized and effects of the medication |
| |are known. |
| |Teach pt to wear/carry identification stating taking MAOI. |
|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 Imipramine (Tofranil)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Sorrow, Chronic related to disease process |
|Obtain complete medical history including allergies, neurological , |Thought Processes, Disturbed related to |
|cardiac (including recent MI) renal, biliary, and mental disorders |effects of drug |
|including EKG and blood studies: CBC, platelets, BUN, creatinine, |Adjustment , Impaired related to |
|liver enzymes and urinalysis. |inadequate drug therapy |
|Obtain patient’s drug history to determine possible drug interactions|Knowledge Deficient , related to drug |
|and allergies |action and side effects |
|Assess neurological status, including seizure activity and |Suicide, Risk for related to inadequate drug |
|identification of recent mood and behavioral patterns |therapy |
| |Urinary retention related to side effects of |
| |drug |
| Planning: Patient Goals and Expected Outcomes |
|The patient will |
|Report mood elevation and will effectively engage in activities of daily living. |
|Report an absence of suicidal ideations and improvement in thought processes. |
|Demonstrate understanding of the drug's action by accurately describing drug effects and |
|precautions. |
|Maintain normal urinary flow |
|Implementation |
|Interventions and (Rationales) |Patient teaching/discharge planning |
|Monitor vital signs especially pulse, and blood pressure. |Instruct the patient to immediately to: |
|(Imipramine may cause orthostatic hypotension.) |Report any change in sensorium particularly impending syncope. |
| |Avoid abrupt changes in posture; rise slowly from prolonged periods of |
| |sitting/lying down. |
| |Monitor vital signs (especially blood pressure) ensuring proper use of |
| |home equipment. |
| |Consult the health care provider regarding "reportable" blood pressure |
| |readings (e.g. "lower than 80/50). |
|Monitor cardiovascular status. |Instruct the patient to immediately report severe headache, dizziness, |
|Observe for hypertension and signs of impending stroke or M.I and |paresthesias, bradycardia, chest pain, tachycardia, nausea/vomiting, |
|heart failure. Use with caution in cardiac patients. |diaphoresis or other distressing symptoms.. |
|Monitor neurological status. |Instruct patient to |
|Observe for somnolence and seizures. (Imipramine causes somnolence |Report significant changes in neurological status, such as seizures, |
|related to CNS depression. Use with caution in epilepsy. Imipramine|extreme lethargy, slurred speech, disorientation or ataxia. |
|may reduce the seizure threshold.) |Take dose at bedtime to reduce daytime sedation. |
|Monitor mental and emotional status. |Instruct the patient: |
|Observe for suicidal ideation. Therapeutic benefits are delayed. |That it may take 10-14 days before any improvement is noticed, and about |
|Out-patients should have no more than a 7-day medication supply. |a month to achieve full therapeutic effect. |
|Monitor for underlying mental disease such as schizophrenia or |To immediately report dysphoria , sleep-wake cycle changes or suicidal |
|bipolar disorders. (Imipramine may trigger manic states.) |impulses. |
|Interview patient regarding suicide potential; | |
|Obtain a "no-self harm" verbal contract. | |
|Monitor renal status |Instruct patient or caregiver to |
|Monitor urinary output. (May cause urinary retention due to muscle |Measure and monitor fluid intake and output. |
|relaxation in urinary tract. Imipramine is excreted through the |Notify the health care provider of the following: edema, dysuria |
|kidneys. Impaired kidney function may result in reduced medication |(hesitancy, pain, diminished stream), changes in urine quantity or |
|clearance and increased serum drug levels. Urinary retention may |quality (eg. cloudy, with sediment) |
|exacerbate existing symptoms of prostatic hypertrophy.) |Report fever or flank pain that may be indicative of a urinary tract |
| |infection related to urine retention. |
|Monitor gastrointestinal status. |Instruct the patient to |
|Observe for abdominal distention. (Muscarinic blockade reduces tone|Exercise, drink adequate amounts of fluid and add fiber to the diet to |
|and motility of intestinal smooth muscle, and may cause paralytic |promote stool passage. |
|ileus.) |Consult the health care provider regarding a bulk laxative or stool |
| |softener if constipation becomes a problem. |
|Monitor liver function. |Instruct the patient to: |
|Observe for signs and symptoms of hepatic compromise. Monitor blood|Report nausea, vomiting, diarrhea, rash, jaundice, epigastric or |
|studies including CBC, differential, platlets, PT, PTT and liver |abdominal pain, tenderness, or change in color of stool. |
|enzymes. |Adhere to laboratory testing regimen for blood tests and urinalysis as |
| |directed. |
|Monitor hematologic status. |Have patient |
|Observe for signs of bleeding. (Imipramine may cause blood |Report the following: excessive bruising, fatigue, pallor, shortness of |
|dyscrasias. If given in hyperthyroidism, can cause |breath, frank bleeding and/or tarry stools. |
|agranulocytosis.) |Demonstrate guiac testing on stool for occult blood. |
|Monitor laboratory blood work (see previous box). Use with warfarin| |
|may increase bleeding time. | |
|Monitor immune/ metabolic status. Use with caution in patients with|Instruct patients with diabetes to: |
|diabetes mellitus and hyperthryroidism. (Imipramine may either |Monitor glucose level daily. |
|increase or decrease serum glucose.) |Consult health care provider regarding reportable serum glucose levels |
| |(eg. "less than 70 and more than 140"). |
|Monitor for adverse drug effects and overdosage. Observe for |Instruct the patient/caregiver: |
|extrapyramidal and anticholinergic effects. (In overdosage, 12 |To immediately report involuntary muscle movement of the face or upper |
|hours of anticholinergic activity is followed by CNS depression. |body (e.g. tongue spasms), fever, anuria, lower abdominal pain, |
|Cardiac dysrthymia may also occur.) |confusion, anxiety, hallucinations, psychomotor agitation, visual |
|Do not treat overdosage with quinidine, procainamide, atropine or |changes, excessively dry mouth and difficulty swallowing. |
|barbiturates. Use of these drugs potentiate cardiac depression. |That mild dry mouth may be relieved by (sugar-free) hard candies, chewing|
| |gum and drinking fluids. |
| |To avoid alcohol containing mouthwashes which can further dry oral mucous|
| |membranes. |
|Monitor visual acuity. Use with caution in narrow-angle glaucoma. |Instruct the patient to |
|(Imipramine may cause an increase in intraocular pressure. |Report any disturbing visual changes, headache or eye pain. |
|Anticholinergic effects may produce blurred vision.) |Inform eye care professional of imipramine therapy. |
|Ensure patient safety. (Dizziness caused by postural hypotension |Instruct the patient to: |
|increases the risk of fall injuries.). Raise bed rails. Place call |Call for assistance before getting out of bed or attempting to ambulate |
|bell within patient's reach. |alone. |
| |Avoid driving or other activities requiring mental alertness or physical |
| |agility until blood pressure is stabilized and effects of the medication |
| |are known |
|Use cautiously with the elderly or young. (Diminished kidney and |Instruct the patient/caregiver that the elderly may be more prone to side|
|liver function related to aging can result in higher serum drug |effects such as hypertension and dysrythmias. Children on imipramine for|
|levels, and may require lower doses. Children, due to an immature |nocturnal enuresis may experience mood alterations. |
|CNS, respond paradoxically to CNS-active drugs.) | |
|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 FLUOXETINE (Prozac)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Body image disturbed, related to weight gain |
|Obtain complete medical history including allergies, neurological, |Anxiety, related to drug effect |
|psychological, cardiac, renal, and liver disorders(including recent |Coping, Ineffective related to inadequate drug therapy |
|history of seizures or suicidal ideation) and including blood |Knowledge Deficient, related to drug action and side effects, |
|studies: glucose, BUN, creatinine, electrolytes, liver function tests|Suicide, Risk for related to early drug therapy |
| |Powerlessness, related to depressive state. |
|Obtain patient’s drug history to determine possible drug interactions| |
|and allergies | |
| Planning: Patient Goals and Expected Outcomes |
|The patient will |
|Report mood elevation and will effectively engage in activities of daily living. |
|Report an absence of suicidal ideations and improvement in thought processes. |
|Demonstrate a decrease in anxiety (e.g. ritual behaviors). |
|Demonstrate understanding of the drug's action by accurately describing drug effects and |
|precautions. |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|Observe for Serotonin Syndrome (SS), a medical emergency. (Serotonin |Inform the patient/caregivers: |
|Syndrome is possible at high doses, and especially combined with |That overdosage may result in serotonin syndrome, which can be |
|MAOIs.) |life-threatening. |
|For suspected SS, stop the drug and initiate supportive care: monitor|To seek immediate medical attention for the following: dizziness, |
|all vital signs, including EKG. |headache, tremor, nausea/vomiting, anxiety, disorientation, |
| |hyperreflexia, diaphoresis and fever. |
|Monitor mental and emotional status. |Instruct the patient: |
|Observe for suicidal ideation (Therapeutic benefits may take a month |That it may take 10-14 days before any improvement is noticed, and |
|or more for ideal response). |about a month to achieve full effect. |
|Monitor for presence of underlying or concomitant mental disorders |To immediately report dysphoria , sleep-wake cycle changes or |
|such as schizophrenia or bipolar disorders. (Fluoxetine may trigger |suicidal impulses. |
|mania.) | |
|Interview patient regarding suicide potential; obtain a "no-self | |
|harm" verbal contract | |
|Monitor neurological status. Observe for seizures. Use with caution |Instruct patient that if seizures occur, stop the drug and contact |
|in epilepsy. (Fluoxetine decreases the seizure threshold.) |the health care provider immediately. |
|Monitor sleep-wake cycle. Observe for insomnia and/or daytime |Instruct the patient with insomnia to: |
|somnolence. |Take the drug very early in the morning to promote normal timing of |
| |sleep onset. |
| |Avoid driving or potentially hazardous activities until effects of |
| |drug are known. |
| |Take medication at bedtime if daytime drowsiness persists. |
|Monitor kidney and liver function by laboratory tests such as CBC, |Advise the patient to inform the health care provider of the |
|BUN, creatinine, PT, PTT, liver enzymes and urinalysis. (Fluoxitene |following: nausea, vomiting, diarrhea, rash, jaundice, |
|is slowly metabolized and excreted, increasing the risk of organ |flank/abdominal pain or tenderness, changes in urinary quantity and |
|damage. Impaired organ function can further increase drug levels.) |quality or in stool color. |
|Monitor metabolic status. Use with caution in diabetics. (Fluoxitene |Instruct diabetic patients to: |
|may cause hypoglycemia initially, and hyperglycemia with drug |Monitor glucose level daily and consult health care provider |
|withdrawal. Fluoxitene may also cause initial anorexia and weight |regarding reportable serum glucose levels (eg. "less than 70 and more|
|loss, but with prolonged therapy may result in weight-gain of up to |than 140"). |
|twenty pounds.) |Instruct the patient that anorexia and weight loss will diminish with|
| |continued therapy. |
| 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 Lithium (Eskalith)

Nursing Process Focus Patients Receiving Lithium (Eskalith)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Risk for Self-Directed Violence related to delusional thinking |
|Obtain complete health history including allergies, drug history, and |Disturbed Thought Processes related to disease process |
|possible drug interactions. |Disturbed Sleep Pattern related to manic excitement |
|Assess mental and emotional status, including any recent suicidal |Sleep Deprivation (in mania) related to manic excitement |
|ideation. |Risk for Fluid Volume Imbalance related side effect of medication |
|Obtain cardiac history (including) EKG and vital signs; renal, and |Impaired Social Interaction related to egocentric behavior |
|liver disorders, and blood studies: glucose, BUN, creatinine, | |
|electrolytes, and liver enzymes. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|● Demonstrate stabilization of mood, including absence of mania and suicidal depression. |
|● Engage in normal activities of daily living and report subjective improvement in mood. |
|● Demonstrate understanding of drug action by accurately describing drug effects and |
|precautions. |
|Implementation |
|Interventions and (Rationales) |Patient Education/Discharge Planning |
|● Monitor mental and emotional status. |● Instruct the patient to keep a symptom log |
|Observe for mania and/or extreme depression. (Lithium should prevent |to document response to medication. |
|mood swings.) | |
|● Monitor electrolyte balance. (Lithium is a salt affected by |Instruct patient to: |
|dietary intake of other salts such as sodium chloride. Insufficient |Monitor dietary salt intake; consume sufficient quantities, especially |
|dietary salt intake causes the kidneys to conserve lithium, |during illness or physical activity. |
|increasing serum |Avoid activities that cause excessive perspiration. |
|lithium levels.) | |
|Monitor fluid balance. (Lithium causes polyuria by blocking effects of|Instruct patient to: |
|antidiuretic hormone.) |● Increase fluid intake to 1 to 1.5 L per day. |
|Measure intake and output. |● Limit or eliminate caffeine consumption |
|Weigh patient daily. (Short-term changes in weight are a good |(caffeine has a diuretic effect that can cause |
|indicator of fluctuations in fluid volume. Excess fluid volume |lithium sparing by the kidneys). |
|increases the risk of HF; pitting edema may signal HF.) |● Notify healthcare provider of excessive |
| |weight gain or loss, or pitting edema. |
|Monitor renal status. (Lithium may cause degenerative changes in the |Instruct patient to: |
|kidney which increases drug toxicity.) Monitor laboratory tests: CBC,|● Immediately report anuria, especially |
|differential, BUN, creatinine, uric acid, and urinalysis. Use with |accompanied by lower abdominal |
|caution in kidney disease. |tenderness, distention, headache, and |
| |diaphoresis. |
| |● Inform healthcare provider of nausea, |
| |vomiting, diarrhea, flank pain or tenderness |
| |and changes in urinary quantity and quality |
| |(e.g., sediment). |
|Monitor cardiovascular status. (Lithium toxicity may cause muscular |Instruct patient to: |
|irritability resulting in cardiac dysrhythmias or angina.) |● Immediately report palpitations, chest pain, |
|● Monitor vital signs including apical pulse. ● Use with |or other symptoms suggestive of myocardial |
|caution in patients with a history |infarction. |
|of CAD or heart disease. |● Monitor vital signs ensuring proper use of |
| |home equipment. |
|● Monitor gastrointestinal status. (Lithium may cause dyspepsia, |● Instruct patient to take the drug with food |
|diarrhea, or metallic taste.) |to reduce stomach upset and report |
| |distressing GI symptoms. |
|● Monitor metabolic status. (Lithium may cause goiter with |● Instruct patient to report symptoms of goiter |
|prolonged use and false-positive results on thyroid tests.) |or hypothyroidism: enlarged mass on neck, |
| |fatigue, dry skin, or edema. |
|Evaluation of Outcome Criteria |
|Evaluate effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |

Nursing Process Focus: Patients Receiving Methylphenidate (Ritalin)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Risk for Delayed Development, related to growth retardation secondary |
|Obtain complete health history including allergies, drug history, and|to methylphenidate. |
|possible drug interactions. |Delayed Growth and Development, related to increased motor activity, |
|Obtain history of neurological, cardiac, renal, biliary, and mental |growth retardation secondary to methylphenidate, unsuccessful |
|disorders including blood studies: CBC, platelets, liver enzymes. |interpersonal relationships. |
|Assess neurologic status, including identification of recent |Imbalanced Nutrition: Less than Body Requirements, related to side |
|behavioral patterns. |effect of medication. |
|Assess growth and development. |Deficient Knowledge, related to drug therapy. |
| |Disturbed Sleep Pattern, related to possible side effect of medication.|
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Experience subjective improvement in attention/concentration and reduction in impulsivity and/or psychomotor symptoms ("hyperactivity"). |
|Demonstrate understanding of the drug's action by accurately describing drug effects and precautions. |
|Implementation |
| Interventions and (Rationales) |Patient Education/Discharge Planning |
|● Monitor mental status and observe for changes in level of |● Instruct patient to report any significant increase in motor |
|consciousness and adverse effects such as persistent drowsiness, |behavior, changes in sensorium, or feelings of dysphoria. |
|psychomotor agitation or anxiety, dizziness, trembling, or seizures. | |
|● Use with caution in epilepsy. (Drug may reduce the seizure |● Instruct patient to discontinue drug immediately if seizures |
|threshold.) |occur and notify healthcare provider. |
|● Monitor vital signs. (Stimulation of the CNS induces the |Instruct patient to: |
|release of catecholamines with a subsequent increase in heart rate |● Immediately report rapid heartbeat, palpitations, or dizziness. |
|and blood pressure.) |● Monitor blood pressure and pulse, ensuring proper use of home |
| |equipment. |
|● Monitor gastrointestinal and nutritional status including side|Instruct patient to |
|effects such as nausea/vomiting, anorexia, and abdominal pain. (CNS |● Report any distressing GI side effects. |
|stimulation causes anorexia and elevates BMR, producing weight loss.)|● Take the drug with meals to reduce GI upset and counteract |
| |anorexia; eat frequent small nutrient and calorie dense snacks. |
| |● Weigh weekly and report losses over one pound. |
|● Monitor laboratory tests such as CBC, |Instruct patient to: |
|differential, and platelet count. (Drug is metabolized in the liver |● Report shortness of breath, profound fatigue, pallor, bleeding, |
|and excreted by the kidneys; impaired organ function can increase |or excessive bruising (these are signs of blood disorder). |
|serum drug levels. Drug may cause leukopenia and/or anemia.) |● Report nausea, vomiting, diarrhea, rash, jaundice, abdominal |
| |pain, tenderness, distention, or change in color of stool (these are |
| |signs of liver disease). |
| |● Adhere to laboratory testing regimen for blood tests and |
| |urinalysis as directed. |
|● Monitor effectiveness of drug therapy. |Instruct the patient to: |
| |Schedule regular drug holidays. |
| |Not discontinue abruptly as rebound hyperactivity or withdrawal |
| |symptoms may occur: taper the dose prior to starting a drug holiday. |
| |Keep a behavior diary to chronicle symptoms and response to drug. |
| |Safeguard medication supply due to abuse potential. |
|● Monitor growth and development. (Growth rate may stall in |● Instruct patient that reductions in growth rate are associated |
|response to nutritional deficiency caused by anorexia.) |with drug usage. Drug holidays may decrease this effect. |
|● Monitor sleep-wake cycle. (CNS stimulation may disrupt normal|Instruct patient that: |
|sleep patterns.) |● Insomnia may be an adverse reaction. |
| |● Sleeplessness can sometimes be counteracted by taking the last |
| |dose no later than 4 p.m. |
| |● Drug is not intended to treat fatigue; warn the patient that |
| |fatigue may accompany wash-out period. |
|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 CHLORPROMAZINE (Thorazine)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Therapeutic regimen management, ineffective |
|Obtain complete medical history, especially of mental illness, |Activity intolerance, risk for related to side effect of drug |
|respiratory, gastrointestinal, genitourinary disorders, alcohol and |Knowledge deficient, related to drug action and side effects |
|illegal drug use. Include blood studies: electrolytes, CBC, BUN, |Constipation related to decreased intestinal motility |
|creatinine, HCG levels if indicated, and drug screens (for use of |Injury, risk for related to drug effects |
|illegal drugs) | |
|Obtain patient’s drug history to determine possible drug interactions| |
|and allergies | |
| Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Experience relief of positive symptoms of schizophrenia, and relief of manic symptoms in patients with schizo-affective disorder |
|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. |
|Adhere strictly to the recommended treatment |
|Abstain from alcohol and illegal drug use |
|Immediately report any occurrence of any adverse reactions |
|Implementation |
|Interventions and (Rationales) |Patient Education and Discharge Planning |
|Monitor for EPS and NMS. Medications may be available to treat EPS. |Teach patient and family to: |
|(Presence of EPS may be sufficient reason for patient to discontinue |Recognize tardive dyskinesia, dystonia, akathesia, pseudoparkinsonism |
|chlorpromazine; NMS is life-threatening and must be reported and |Recognize and seek treatment immediately for elevated temperature, |
|treated immediately.) |unstable blood pressure, profuse sweating, dyspnea, muscle rigidity, and|
| |incontinence |
|Monitor for “cheeking”, hoarding or sharing medication. Observe |Teach patient/family: |
|patient closely for noncompliance. (If therapeutic results are not |Importance of taking medication exactly as ordered, and not sharing it |
|seen, patient may not be taking medication as ordered, even though |with anyone |
|he/she may appear to be taking it.) |How to check to be sure patient has swallowed medication |
|Observe for side effects such as orthostatic hypotension, |Instruct patient to: |
|constipation, anorexia, GU problems, respiratory changes, visual |Change position and arise slowly |
|disturbances. (These side effects are caused by the anticholinergic |Not to drive a car until he/she is stabilized on chlorpromazine and |
|effects of chlorpromazine.) |sedating effects are known |
| |Report vision changes |
| |Comply with required laboratory tests as ordered, e.g, Thorazine levels,|
| |electrolytes, CBC, BUN, and creatinine. |
| |Increase roughage in diet, increase fluids, and increase exercise to |
| |decrease or avoid constipation |
|Monitor for use of medication. (Medication must be gradually withdrawn|Instruct patient: |
|over a 2-3 week time, or patient may experience nausea/vomiting, |To continue taking the medication as ordered, even if not therapeutic |
|dizziness, tremors, or dyskinesia.) |benefits are felt. |
| |That it may take 6 weeks-6 months for full therapeutic benefits. |
|Monitor patient for respiratory depression, laryngospasm, dyspnea. |Instruct patient that if any respiratory symptoms occur, their health |
| |care provider must be notified. |
|Monitor for caffeine use. (Caffeine will cause a decreased therapeutic|Instruct patient to avoid caffeine in common products contain caffeine, |
|response of chlorpromazine.) |including: coffee, tea, carbonated beverages, and chocolate. |
|Monitor patient’s environment. (Chlorpromazine may cause patient to |Instruct patient: |
|perceive brownish discoloration of objects or photophobia. |Wear dark glasses to avoid discomfort from photophobia |
|Chlorpromazine may also interfere with the body’s ability to regulate |Avoid temperature extremes. |
|body temperature.) | |
|Observe for evidence of alcohol/illegal drug use. (The patient may use|Instruct the patient to refrain from alcohol/illegal drug use. |
|alcohol/illegal drugs as means as coping with symptoms of psychosis.) | |
|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 CLOZAPINE (Clozaril)

|Assessment |Potential Nursing Diagnoses |
|Prior to administration: |Anxiety related to disease process |
|Assess for hallucinations, mental status, dementia, bipolar disorder |Injury, risk for related to effects of drug |
|(initially and throughout therapy). |Noncompliance, related to side effects of drug |
|Obtain complete medical history, especially psychological, neurologic |Sleep pattern, disturbed, related to drug effect |
|and blood diseases: including blood studies: CBC, WBC with |Knowledge deficient, related to drug action and side effects |
|differential, electrolytes, BUN, creatinine, liver enzymes. | |
|Obtain patient’s drug history to determine possible drug interactions | |
|and allergies. | |
|Planning: Patient Goals and Expected Outcomes |
|The patient will: |
|Report a reduction of psychotic symptoms, including delusions, paranoia, irrational behavior |
|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 |
|Adhere to recommended therapy, including medications, psychotherapy, health care provider and lab appointments |
|Refrain from alcohol, caffeine, smoking, other CNS depressants |
|Implementation |
|Interventions and (Rationales) |Patient Education and Discharge Planning |
|Monitor RBC and WBC counts. If WBC levels drop < 3500, medication will|Advise patient of the importance of having weekly lab studies done. |
|need to be stopped immediately. (Patient may be developing | |
|agranulocytosis, which could be life-threatening.) | |
|Monitor for hematologic side effects. (Neutropenia, leukopenia, |Instruct patient to report immediately any sore throat, signs of |
|agranulocytosis, thrombocytopenia may occur, secondary to possible |infection, fatigue, bruising, without apparent cause. |
|bone marrow suppression caused by clozapine.) | |
|Observe for side effects such as drowsiness, sedation, dizziness, |Instruct patient to report side effects to the health care provider. |
|depression, anxiety, tachycardia, hypotension, nausea/vomiting, | |
|excessive salivation, urinary frequency or urgency, incontinence, | |
|weight gain, muscles pain or weakness, rash, fever. Report | |
|immediately. | |
|Monitor for side effects: mouth dryness, constipation, urinary |Inform patient that: |
|retention. Urinary retention may be corrected only by use of an |Mouth dryness and constipation can be decreased with sugarless gum or |
|indwelling catheter. |candy, increased fluids, frequent sips of water, increased fruits and |
| |vegetables in diet |
| |If urinary retention occurs, notify health care provider immediately to |
| |prevent complications |
|Monitor for decrease of psychotic symptoms. (Medication is working as |Teach patient/family to: |
|it should if patient exhibits more normal thoughts and behaviors. If |Look for more normal behaviors (completing own ADLs, showing more |
|patient continues to exhibit symptoms of psychosis, either he is not |interest in surroundings, more normal sleep patterns, etc.), to notice |
|taking medications as ordered, he is taking an inadequate dose, or he |decrease or absence of symptoms of psychosis, including hallucinations, |
|is immune to it and it will need to be discontinued and another |delusions, paranoia, etc. |
|anti-psychotic begun.) |Contact health care provider if no decrease of symptoms occurs over a six|
| |week period |
|Monitor for alcohol use. (Alcohol used concurrently with clozapine |Instruct patient: |
|will cause increased CNS depression. Patient may decide to stop taking|Refrain from alcohol use; refer to Alcoholics Anonymous or another |
|clozapine because he wishes to use alcohol.) |support group if indicated |
| |Take medication as ordered; do not stop medication and drink alcohol |
|Discourage caffeine use. (Use of caffeine-containing substances will |Inform patient of common caffeine-containing products, including coffee, |
|negate effects of clozapine.) |tea, carbonated beverages, chocolate, etc. |
|Encourage smoking cessation. (Heavy smoking may decrease blood levels |Instruct patient to stop or decrease smoking; refer to smoking cessation |
|of clozapine.) |programs if indicated. |
|Monitor elderly closely, and give lower doses. (They may be more |Teach elderly patients ways to counteract anticholinergic effects of |
|sensitive to anticholinergic effects.) |medication, while taking into account any other existing medical |
| |problems. |
|Evaluation of Outcome Criteria |
|Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see “Planning”). |