Nursing Process Focus: Patients Receiving Zidovudine (Retrovir)

Transcription

1 Prior to administration Assess for presence or history of viral Assess complete blood count, CD4 count, liver and kidney function. Obtain history of sensitivity to Zidovudine. Patients Receiving Zidovudine (Retrovir) Risk for Infection, related to decreased CD4 count Risk for Injury (dizziness), related to adverse Pain (headache), related to adverse effects of drug therapy Ineffective Tissue Perfusion, related to bone marrow depression secondary to adverse Remain free of side effects, including headache, insomnia, confusion, petechiae, nausea, vomiting, rash, fever and muscle pain. Demonstrate understanding of all lifestyle modifications necessary for successful completion of drug therapy. Maintain adequate tissue perfusion. *Observe for signs and symptoms of infection or bleeding. (Patient may develop granulocytopenia or thrombocytopenia.) *Monitor use of acetaminophen. (Concurrent use of acetaminophen may increase chance of bone marrow depression.) *Monitor weight. (Weight gain may indicate positive effect of drug therapy and absence of GI distress.) that medication may decrease the level of HIV infection in the blood but will not prevent transmitting the disease. to use barrier protection during sexual activity. Instruct patient: not to use acetaminophen while on drug therapy. that acetaminophen is often used with cold product preparations. to take medication 1 hour before meals. to report GI distress to the health care provider. *Instruct patient to report changes in urinary output to the health care provider. *Advise patient to keep all laboratory *Monitor intake and output (may cause renal dysfunction.) *Monitor complete blood count and CD4 counts weekly (to evaluate effectiveness of therapy.)

2 Prior to administration Assess for presence/history of HIV Assess liver function, kidney function, complete blood count, CD4 count, and routine chemistry panel. Patients Receiving Nevirapine (Viramune) Risk for Infection (opportunistic), related to decreased CD4 counts Risk for Injury, related to drowsiness secondary to drug therapy Pain (headache), related to adverse effects of drug therapy Body Requirements, related to adverse Maintain adequate nutrition. Remain free of opportunistic infections. Demonstrate understanding of all lifestyle modifications necessary for successful completion of drug therapy. Immediately report fever, nausea, diarrhea, jaundice and rash. *Monitor for any sign of rash. Withhold medication and notify health care provider at first sign of rash. (Medication may cause Steven-Johnson syndrome which may be fatal.) *Monitor weight (may cause anorexia.) to check skin frequently and notify health care provider at first sign of any rash. that headache may be treated with OTC medications. If these are not effective notify the health care provider. to use non hormonal methods of birth control while taking this medication. *Advise patient to report continuous weight loss to health care provider. *Advise patient to take this medication with food to minimize gastrointestinal distress. *Advise patient to keep all laboratory *Monitor intake and output (to evaluate renal function, and development of GI distress). *Periodically monitor complete blood count, liver function and kidney function test as well as respiratory status with periodic chest x-ray. *Keep bed at lowest level and assist patient *Advise patient not to drive or operate heavy with ambulation due to dizziness. machinery until reaction to this drug is known.

3 Patients Receiving Saquinavir Mesylate (Fortovase) Assessment Prior to administration: Assess for presence/history advanced HIV Assess for concurrent use of Rifampin. Assess complete blood count, CD4 count, blood sugar, electrolytes, vision and hearing levels, and liver function. Risk for Infection, related to ineffective response to drug therapy Body Requirements, related to adverse Risk for Injury (syncope), related to adverse Remain free of side effects including numbness, dizziness, confusion, convulsions, chest pain, syncope and rash. Maintain balanced nutrition including weight at expected levels. Demonstrate understanding of necessary lifestyle modifications for successful completion of drug therapy. *Monitor for signs of bleeding. (Patients with HIV and hemophilia have experienced bleeding episodes while taking this medication.) *Monitor blood sugar frequently in diabetics to assess for hyperglycemia. (There is an increased incidence of hyperglycemia.) *Monitor weight and buccal mucosa for first signs of stomatitis. (This may indicate GI disturbance, including anorexia and food intolerance.) *Monitor electrolytes, complete blood count, CD4 count, liver function, blood glucose, CPK and serum amylase periodically (to evaluate drug effectiveness and evidence of organ toxicity.) *Monitor vision and hearing periodically to assess early changes. *Monitor for any signs of peripheral neuropathy. to take medication with a full meal. that this medication will not cure HIV. to continue to use barrier devices during sexual intercourse. Instruct diabetic patient: to increase blood glucose monitoring/ to report hyperglycemia to health care provider/ to be alert for mouth ulcers. to report the appearance of ulcers to the health care provider. *Instruct patient to keep all laboratory *Instruct patient to report any changes in sight or hearing to the health care provider. *Advise patient to use caution when in contact with heat and cold due to possible peripheral neuropathy. outcomes have been met (see Planning ).

4 Prior to administration: Assess for presence/history viral infections. Assess renal function, complete blood count, viral culture, and vital signs. Assess for herpes simplex Patients Receiving Acyclovir (Zovirax) Risk for Infection, related to ineffective response to drug therapy Body Requirements, related to nausea, vomiting and diarrhea secondary to adverse Risk for Injury (seizures), related to adverse Demonstrate understanding of intended and the lifestyle modifications necessary to achieve intended drug effect. Maintain weight within expected levels. Remain free of side effects including headache, confusion, seizures, flank pain, hematuria, rash and petechiae. *Monitor complete blood count periodically. (Drug may cause thrombocytopenic purpura or hemolytic uremic syndrome.) *Monitor renal status. (Acute renal failure may result if administered with other nephrotoxic drugs.) *Monitor intake and output. (Medication may cause anorexia and stomatitis.) *Observe for evidence of GI distress. *Observe IV site closely and stop infusion at first sign of infiltration. (Drug causes severe inflammation at the site of infiltration.) *to report occurrence of unusual bleeding and bruising to the health care provider. *to increase fluid intake while on drug therapy to prevent dehydration. *that drug therapy is most effective when begun soon after the start of symptoms. *to refrain from sexual activity until no symptoms of herpes infection remains. *that recurrences of herpes simplex infection may be precipitated by stress, trauma or other physical illness. Instruct patient: To report all medications taken to the health care provider. To report changes in urinary output. to report symptoms of ulcerations of the mouth to the health care provider. to report inability to tolerate meals. *Advise patient that medication may be taken with food to decrease gastrointestinal distress. *Instruct patient to immediately report burning pain at the IV site to the health car provider.

5 *Periodically monitor BUN, serum creatinine and urinalysis. (Renal dysfunction may occur.) *Instruct patient to report changes in urinary output to the health care provider.