Nitroglycerin Nursing Focus Semester 3 Med Specific PDF

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Summary

All details are included into the notes. A peace of advice is to active recall everyday and you will succeed....

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NURSING PROCESS FOCUS Clients Receiving Nitroglycerin Assessment

Potential Nursing Diagnoses

Prior to administration: Obtain a complete health history including allergies, drug and alcohol history, and possible drug interactions. Obtain vital signs, ECG, and frequency and severity of angina. Obtain history of cardiac disorders and serum labs, including cardiac enzymes, CBC, BUN, creatinine, and liver enzymes. Assess if client has taken sildenafil (Viagra) in past 24 hours, because it may cause MI. ■

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Tissue Perfusion, Ineffective, related to hypotension due to drug. Injury, Risk for, dizziness or syncope related to hypotension Pain, Acute (headache) related to adverse effects of drug Knowledge, Deficient, related to drug therapy

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Planning: Client Goals and Expected Outcomes The client will: Experience relief or prevention of chest pain. Immediately report chest pain unrelieved by nitroglycerin. Demonstrate an understanding of the drug’s actions by accurately describing drug side effects and precautions. ■ ■ ■

Implementation Interventions and (Rationales) ■

Client Education/Discharge Planning

Assess client’s level of pain, including location, quality and intensity. (Assessment aids in determining drug dose.)

Instruct client: If after three doses, chest pain has not subsided, to call for emergency services. To sit or lie down prior to taking nitroglycerin and maintain position for a few minutes. Not to ingest any alcohol while taking nitroglycerin. ■ ■

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Monitor ECG, blood pressure, and pulse. (Assessment aids in determining drug dose.)

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Assess for headache. (Nitrates commonly cause headache.)

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Assess for use of sildenafil. (The combination may lead to severe hypotension.)

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Inform client to monitor blood pressure and pulse daily. Inform client that headache is a common side effect that usually resolves over time. Instruct client to not take sildenafil (Viagra) within 24 hours after taking nitrates, and wait 24 hours after taking Viagra to resume nitrate therapy.

Evaluation of Outcome Criteria Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see “Planning”). The client is free of chest pain. The client verbalizes the importance of notifying the healthcare provider of unrelieved chest pain. The client demonstrates an understanding of the drug’s action by accurately describing drug side effects and precautions.

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