Nursing Process Focus:

Patients Receiving Phenobarbital (Luminal)

Assessment
Prior to administration:
  • Obtain complete health history, including allergies, neurological, pulmonary, cardiac, renal, biliary, and mental disorders including blood studies: CBC, BUN, creatinine, electrolytes, PT, PTT, liver enzymes, etc.
  • Obtain patient’s drug history to determine possible drug interactions and allergies
  • Assess neurological status, including identification of recent seizure activity.
/ Potential Nursing Diagnoses
  • Sensory perception, Disturbed related to effects of drug.
  • Injury, Risk for, related to seizure activity
  • Nutrition: less than body requirements, Imbalanced, related to vitamin deficiency
  • Knowledge, Deficient related to newly prescribed drug.
  • Sleep Pattern, Disturbed. related to medication induced somnolence

Planning: Patient Goals and Expected Outcomes
Patient will
  • Experience the absence of, or reduction in the number or severity of, seizures.
  • Avoid physical injury related to seizure activity or medication induced somnolence
  • 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 blood pressure and depth and rate of respirations. (Because phenobarbital produces sedation, respiratory depression occurs.)
  • Keep resuscitative equipment accessible (Phenobarbital may produce laryngospasm)
/ Instruct the patient to:
  • monitor vital signs regularly, particularly blood pressure and respirations.
  • withhold medication for any difficulty in breathing or respirations below 12 breaths per minute.

  • Perform neuro-checks regularly, including level of consciousness (LOC), according to unit protocol. Excessive somnolence may occur. Observe for persistent seizures.
/ Instruct the patient to:
  • Report any significant change in sensorium: lethargy, stupor, or auras, visual changes and other effects that may indicate an impending seizure.
  • Report dizziness which may indicate hypotension.

  • Monitor response to and effectiveness of drug therapy
/ Instruct the patient to:
  • Be aware that drug will cause initial drowsiness; this effect may diminish with continued therapy
  • Avoid potentially hazardous activities that require mental alertness (driving, operating equipment etc)
  • Bear in mind that full therapeutic effect of oral phenobarbital may take 2-3 weeks;
  • Not discontinue abruptly, or reduce dosage, as increased seizure activity and/ or withdrawal symptoms may occur
  • Keep a seizure log or diary to chronicle symptoms

  • Ensure patient safety by monitoring ambulation until response of the drug is known.Elevate bed rails; place call bell within patient's reach.
/ Instruct the patient to:
  • Call for assistance when getting out of bed or attempting to walk.
  • Remove any tripping hazards from the home environment.

  • Monitor for adverse reactions, especially due to CNS depression: confusion, agitation, nightmares, GI upset, lethargy, anxiety, cognitive changes, etc. (Changes in response to medication may indicate toxicity and requires evaluation.) Report immediately.
/
  • Instruct patient to immediately report any idiosyncratic or disabling effects.

  • Monitor for signs of vitamin deficiency. (Phenobarbital increases metabolism of the nutrients Vitamin D, Vitamin K, folate and other B vitamins. Vitamin D deficiency results in impaired bone synthesis, Vitamin K deficiency results in impaired blood coagulation, other deficiencies result in impaired cellular reproduction and repair, causing anemia.)
  • Obtain consult with dietitian per health care provider's order as needed.
/ Instruct the patient or caregiver:
  • Regarding the role of vitamins and nutrition in maintaining health. Instruct the patient to immediately report signs of vitamin deficiency. Vitamin K: easy bleeding (nasal, oral,rectal, etc.), tarry stools, bruising, pallor. Vitamin D: Joint pain, bone deformities. Vitamin B6: skin changes, dandruff (seborrhea), peripheral neuropathy, fatigue.
  • Regarding intake of a nutrient-rich diet.

  • Monitor for signs of hepatic or renal toxicity. (Phenobarbital is metabolized by the liver and excreted by the kidneys.)
  • Monitor laboratory blood tests and urinalysis: CBC with differential, electrolytes, BUN, PT, PTT, liver enzymes, etc. (Impaired function results in increased serum drug levels.)
/ Instruct the patient to:
  • Observe for signs of toxicity: nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness or distention, or change in color of stool, flank pain, hematuria.
  • Adhere to a regular schedule of laboratory testing for liver and kidney function as ordered by the health care provider

  • Use with caution in children, the elderly and those with pre-existing diseases, such as respiratory disorders. These patients require reduced dosages. Paradoxical response to drug may occur, which may cause psychomotor agitation (hyperactivity).
/ Instruct patient and caregiver:
  • That children respond differently because their nervous systems are not yet fully mature.
  • The elderly are more susceptible to the effects of phenobarbital due to increased serum drug levels related to reduced efficiency of the liver and kidneys as a result of aging.

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 Phenytoin (Dilantin)

Assessment

Prior to administration:
  • Obtain complete medical history including allergies, developmental, neurological , pulmonary, cardiac, hematological, renal, biliary, and mental disorders including blood studies: CBC, BUN, creatinine, electrolytes, PT, PTT, liver enzymes, etc.
  • Obtain patient’s drug history to determine possible drug interactions and allergies
  • Assess neurological status, including identification of recent seizure activity.
  • Assess growth and development
/

Potential Nursing Diagnoses

  • Knowledge deficient related to drug regimen, action, and side effects
  • Altered nutrition:Nutrition altered less than body requirements, Imbalanced related to nutrient deficiency
  • Oral mucous membrane, Impaired related to drug effects.
  • Skin integrity, Risk for impaired related to adverse drug reaction
  • Injury, Risk for, related to drug side effects

Planning: Patient Goals and Expected Outcomes
The patient will:
  • Report absence of seizure activity.
  • Demonstrate understanding of drug action by accurately describing drug side effects and precautions.
  • Demonstrate proper daily oral hygiene.

Implementation

Interventions and (Rationales)

/ Patient Education/Discharge Planning
  • During IV infusion, monitor all VS and EKG. May need to ensure that patient’s cardiac output and central venous pressure be monitored according to ICU or ED protocols.
/
  • Instruct the patient to immediately report:
any difficulty breathing, palpitations, chest
pain, dizziness or impending syncope.
  • Monitor neurological status, especially changes in level of consciousness and/or mental status. (At high doses, phenytoin may produce respiratory depression and delirium.
  • Phenytoin may have a paradoxical effect,
producing involuntary movements such as
dyskinesia or chorea.) / Instruct the patient:
  • Report any significant change in sensorium, such as slurred speech, confusion, hallucinations, or extreme lethargy.
  • Report any changes in seizure quality or unexpected involuntary muscle movement, such as twitching, tremor or nystagmus.
  • Avoid driving and other activities requiring mental alertness and physical coordination until effects of the medication are known.

  • Monitor for adverse immune reaction, such as hypersensitivity syndrome and dermatological manifestations such as purpuric dermatitis or Stevens-Johnson syndrome.
/ Instruct the patient to:
  • Immediately report shortness of breath, wheezing, tightness in the throat, itching or any changes in the skin such as a measles-like ("morbilliform") rash or dermatitis fever, joint pain, profound fatigue
  • Call the health care provider immediately (before the next scheduled dose) for any adverse reaction
  • Keep in mind that abrupt cessation of the drug can cause rebound seizures.

  • Monitor effectiveness of drug therapy.
  • Observe for developmental changes indicating the need for dose adjustment. (Phenytoin needs increase with initial maturing, especially at puberty, a time of rapid growth.)
/ Instruct patient to:
  • Keep a "seizure diary" during drug initiation phase, or during dose adjustment.
  • Take the medication exactly as ordered, including the same manufacturer's drug each time the prescription is refilled. Switching brands may result in alterations in seizure control.
  • Take a missed dose as soon as remembered, but do not double doses to "catch up" (doubling doses could result in toxic serum level)

  • Use cautiously in the elderly. (Diminished kidney and liver function related to aging result in lowered drug clearance and increased serum drug levels.)
/ Instruct patient to:
  • Keep all appointments for follow-up lab studies
  • Report signs of toxicity to the health care provider immediately

  • Monitor oral health. Observe for signs of gingival hypertrophy, bleeding, inflammation, etc.
/ Instruct the patient to:
  • Use a soft toothbrush, and oral rinses as prescribed by the dentist.
  • Avoid mouthwashes containing alcohol, which dries mucous membranes.
  • Brush and floss teeth after every meal; massage the gums daily.
  • Report changes in oral health such as excessive bleeding or inflammation of the gums
  • Maintain regular schedule of dental visits.

  • Provide patient with information concerning contraceptive use. (Phenytoin may reduce the effectiveness of oral contraceptives.)
/ Instruct the patient:
  • Remain abstinent or use reliable birth control while taking this medication.
  • Inform the health care provider if pregnancy occurs
  • Avoid abrupt cessation of the drug; rebound seizures may cause harm to the fetus
  • Phenytoin dose requirements increase during pregnancy.

  • Monitor serum glucose and observe for signs of diabetes mellitus. (Phenytoin alters glycemic control and may cause hyperglycemia.)
/ Instruct the patient to:
  • Observe for subtle signs of hyperglycemia (e.g. polydipsia, polyuria, slow wound healing, etc.)
  • Regularly monitor blood and/or urine glucose levels as specified by the health care provider
  • Adhere to a calorie-controlled low refined sugar (or ADA) diet as prescribed by the health care provider.

Monitor laboratory tests such as CBC,

BUN, creatinine, electrolytes including
serum calcium, urinalysis and liver enzymes
to determine kidney and liver function.
(Phenytoin is metabolized in the liver and
excreted by the kidneys; impaired organ
function can increase serum drug levels.) / Instruct the patient to:
  • Report shortness of breath, profound fatigue, pallor (signs of anemia)
  • Report nausea, vomiting, diarrhea, rash, jaundice, abdominal pain, tenderness, distention, or change in color of stool.
  • Adhere to laboratory testing regimen for blood tests and urinalysis as directed.

  • Include effects of phenytoin use on lab tests in teaching plan.
*Reduces free thyroxine levels
*Reduces 17 keto-steroid levels
*Decreases dexamethasone suppression values, and urine 6-b hydroxycortisol levels. / Inform the patient that:
  • Phenytoin may cause false positive resultsw on tests for hypothyroidism, ant other endocrine tests.
  • Should inform patient to notify laboratory personnel of phenytoin drug therapy when providing blood or urine samples.

  • Monitor nutritional status. (Phenytoin's action on electrolytes at the cellular level [desensitizing sodium channels] contributes to decreased absorption of folic acid, vitamin D, magnesium and calcium. Folic acid deficiency leads to anemia; vitamin D, magnesium and calcium deficiencies lead to osteoporosis.)
/ Instruct the patient to:
  • Eat well balanced meals high in vitamins and nutrients.
  • Regularly take vitamin and mineral supplements (Vitamin D, folic acid, magnesium, and calcium) as recommended by the health care provider.

  • Observe patterns of elimination. (Phenytoin's central nervous system depressant effects decrease gastrointestinal motility, producing constipation.)
/ Instruct patient to:
  • Take the drug with food to reduce gastrointestinal upset.
  • Immediately report any severe or persistent heartburn, upper G.I. pain, nausea or vomiting.
  • Increase exercise, fluid and fiber intake to facilitate stool passage
  • Consult the health care provider regarding the need for a bulk laxative or stool softener for chronic constipation.

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 Ethosuximide (Zarontin)

Assessment

Prior to administration:
  • Obtain complete medical history: neurological, hematological, pulmonary, cardiac, renal, biliary, and mental disorders including blood studies: CBC, BUN, creatinine, electrolytes,PT, PTT, liver enzymes, etc.
  • Obtain patient’s drug history to determine possible drug interactions and allergies
  • Assess neurological status, including identification of recent seizure activity.
  • Assess mental status, including affect and lucidity.
  • Assess gastrointestinal status, including
identification of biliary tract or upper
digestive discomfort
  • Assess growth and development.
/

Potential Nursing Diagnoses

  • Knowledge deficient related to drug therapy, side effects and precautions.
  • Thought processes, Disturbed related to side effects of drug.
  • Nutrition: less than body requirements, Imbalanced, related to weight loss
  • Oral mucous membrane, Impaired, related to drug side effects.
  • Injury, Risk for related to drug side effects.

Planning: Patient Goals and Expected Outcomes
The patient will:
  • Experience the absence of, or a reduction in, the number or severity of seizures.
  • Avoid physical injury related to seizure activity or medication induced sensory changes.
  • Demonstrate understanding of the drug's action by accurately describing drug effects and
precautions
  • Maintain intact mucous membranes

Implementation
Interventions and (Rationales) / Patient Education/Discharge Planning
  • Monitor vital signs especially temperature
and respiratory patterns, especially
during sleep. / Instruct patient:
  • Regarding methods to monitor vital signs at home, especially temperature and respirations, ensuring proper use of home equipment. Elevated temperature may result from infection or indicate a blood disorder.
  • That snoring is NOT normal; it is a sound
created by obstruction in the upper
respiratory tract which may signal sleep
apnea and should be reported.
  • Monitor neurological status, especially changes in level of consciousness and/or mental status.
/ Instruct the patient to:
  • Report any significant change in sensorium such as visual changes (myopia), confusion, difficulty concentrating, hallucinations, or psychomotor agitation.
  • Report dizziness, headache, lethargy, fatigue, ataxia, sleep pattern disturbances or hiccups.
  • Report any changes in seizure quality or unexpected involuntary muscle movement.
  • Avoid driving and other activities requiring mental alertness and physical coordination until effects of the medication are known.

  • Observe for psychosis and/or labile emotions, especially mental depression.
  • Obtain a verbal "no-self-harm" contract from patients with significant mental depression.
/
  • Instruct patient to report any severe dysphoria, especially suicidal ideation.

  • Monitor for adverse hypersensitivity reaction, including dermatological manifestations / Stevens-Johnson syndrome.
/ Instruct the patient to:
  • Immediately report shortness of breath, wheezing, tightness in the throat, itching or any changes in the skin such as rash or dermatitis
  • Call the health care provider immediately (before the next scheduled dose) for any adverse reaction
  • Keep in mind that abrupt cessation of the drug can cause rebound seizures.

Monitor immune status.
  • Observe for signs of infection which may indicate insidious onset of blood dyscrasia: fever, sore throat, malaise, joint pain, ecchymoses, profound fatigue, shortness of breath, pallor, etc. Report immediately.
/ Instruct the patient or caregiver
  • Immediately report any "flu-like" symptoms: shortness of breath, fever, sore throat, malaise, joint pain, profound fatigue, etc.
  • Flu-like symptoms may herald the "silent" onset of serious blood disorder, such as bone marrow suppression.
  • Bruising is a sign of bleeding which can also indicate the presence of a serious blood disorder.

Monitor laboratory tests such as CBC,

BUN, creatinine, electrolytes, (including
serum calcium), PT, PTT, liver enzymes
and urinalysis, to determine kidney and
liver function. (Ethosuximide is
metabolized in the liver and excreted by the
kidneys; impaired organ function may
result.) / Instruct the patient to:
  • Immediately report any distressing symptoms to the health care provider.
  • Adhere to laboratory testing regimen for blood tests and urinalysis as directed by the health care provider.

Monitor renal function.
  • Monitor intake & output
  • Observe for signs of nephrotoxicity, including oliguria and pitting edema.
  • Monitor laboratory values (see previous box above).
/ Instruct the patient to:
  • Monitor fluid intake and output.
  • Immediately report changes in urine color, character or output (hematuria, oliguria, cloudiness, etc.)
  • Immediately report nausea, fever, malaise and/or flank pain.

Monitor gastrointestinal status.
  • Observe for signs of gastrointestinal bleeding or hepatic toxicity. Monitor gastrointestinal elimination; conduct guiac stool testing for occult blood.
/ Instruct the patient:
  • Report any frank bleeding, abdominal pain, anorexia, heartburn, nausea, vomiting, jaundice or a change in the color or character of stools. Vomiting brown emesis that looks like coffee grounds or passing tarry stools are signs of gastrointestinal bleeding.
  • Regarding the method of obtaining stool samples and home testing for occult blood as indicated by the health care provider.
  • Adhere to a regimen of laboratory testing as ordered by the health care provider and keep all follow-up appoints as scheduled.

Monitor nutritional status.
  • Observe for weight loss secondary to anorexia.
/ Instruct patient:
  • Measure body weight weekly
  • Inform the health care provider of losses, especially greater than two pounds
  • Regarding measures to enhance weight maintenance and appetite: small frequent meals, calorie-dense snacks, nutritional supplement drinks, etc.
  • Consult with a nutritionist or dietician as ordered by the health care provider.

Monitor effectiveness of drug therapy.
  • Observe for developmental changes indicating the need for dose adjustment.
  • (Ethosuximide needs increase with initial maturing, especially at puberty, a time of rapid growth.)
/ Instruct the patient
  • Take the medication exactly as ordered, including the same manufacturer's drug each time the prescription is refilled. Switching brands may result in alterations in seizure control.
  • Take a missed dose as soon as remembered, but do not double doses to "catch up" (doubling doses could result in toxic serum level)

  • Use cautiously in the elderly. (Diminished kidney and liver function related to aging result in lowered drug clearance and increased serum drug levels.)
/
  • Instruct the patient to report symptoms of drug toxicity such as visual changes, hallucinations, headache, or dizziness.

  • Inform patient of need to use alternate forms of birth control. (Drug may decrease effectiveness of oral contraceptives.)
/ Instruct the patient:
  • Remain abstinent or use reliable birth control while taking this medication.
  • Inform the health care provider if pregnancy occurs
  • Avoid abrupt cessation of the drug; rebound seizures may result.

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: