CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Patient Data
Student: Kaylee Blankenship Date of Care: 3/12/15-3/13/15 Room Number: 4721-A Code Status: FULL
Pt. Initials

D.R. Gender: Female Age: 88 Height: 5 Weight: 50.1 kg (110 lbs) BMI: 21 Spirituality: Protestant Ethnicity: Caucasian

Admitting Diagnosis: Hypoglycemia

Vital Signs: Temp 97.7 F (36.5 C) HR 110 RR 18 B/P 159/65 O2 Sat 95 Pain Scale & Scale Type 0 out of 10
History related to this admission: type II DM w/o mention of complication
Past Medical History: HTN essential. Abnormal heart sounds, motion sickness, type II DM w/o mention of complication, arthropathy unspecified,
cervcalgia, GERD, hyperlipidemia
Admit Date: 3/9/15 POD: :
Surgical History & Date: shoulder surgery-left side (2008), left knee replacement (2000), appendectomy (1945), tonsil removal (less than 12 yr),
extracap cataract removal w/IOL (9/2009)
MD(s): Ahire
Diet: soft diet w/ 1:1 feeder Activity: ambulate with assist
Feeding Tube & Rate :
Advance Directive: Yes ________ No X
Isolation:
VS Freq: q4hr per unit protocol
Vascular Access:

Foley: indwelling single lumen cath (3/9/15)

Drains/ Tubes:
Glucose Monitoring: yes (AC and HS) DVT Prophylaxis: SCDs
PCA/Epidural:
Telemetry & Rhythm: 5-lead (sinus tachycardiamost of the time)
IV Site: right forearm IV Solution & Rate: NaCl 0.9% 75 ml/hr Safety Considerations: fall precautions, aspiration, confusion, restraints
Restraints: side rails up, vest/jacket, soft bilateral wrist restraints on 3/11/15. Had no restraints and just a sitter 3/12/15-3/13/15
Dressing Changes & Frequency:
Labs for day of clinical: BMP w/ GFR routine daily, Mg routine daily am, Mg routine after replacement prn, K routine after replacement prn, CBC
with auto differential routine daily
Scheduled Procedures: Echocardiogram 3/13/15
Procedures done this admission:
Oxygen: room air
Respiratory Treatment:
Vent Settings:
Allergies: NKDA
Advanced Hemodynamic Monitoring & Values:
IV Drips Medications Dosage & Rate:

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N4810 Clinical Paperwork Rev 11/6/13

Notes on Pathophysiology
Medication
Generic & Trade Name Dose,
Route, Frequency
Acetaminophen (Tylenol)
650 mg PO q4hr prn

Mechanism of Action
Classification
Analgesic, antipryretic;
synthetic nonopioid paminophenol derivative

Patient-Specific Rationale
For mild pain 1-3 or temp above 38
degrees C as indicated on MAR. Pt has
arthropathy which can sometimes casue
mild aches and pains.

Action: Pain reduction may result

from inhibition of prostaglandin
synthesis in CNS, with subsequent
blockage of pain impulses. Fever
reduction may result from
vasodilation and increased
peripheral blood flow in
hypothalamus.

Ascorbic acid (vitamin C)

1,000 mg PO daily

Aspirin
81 mg tab PO chewable daily
with breakfast

Vitamin C-water soluble vitamin

Dietary supplement for deficiency.

Action: wound healing collagen

synthesis, antioxidant,
carbohydrate metabolism

Analgesic; NSAID
- Action: A potent inhibitor of
both prostaglandin synthesis and
platelet aggregation than its other
salicylic derivatives due to the
acetyl group on the aspirin
molecule, which inactivates
cyclooxygenase via acetylation.

Decreases platelet aggregation (blood

thinner), which is what the patient needs
in order to help prevent blood clots. Pt
also has history of HTN.

Nursing Considerations
(Assessment implications, side effects, reasons to hold
med, administration rate, etc)
Side effects: Pruritis, constipation, nausea, vomiting,
insomnia, agitation, atelectasis, Stevens-Johnson
syndrome, toxic epidermal necrolysis, pneumonitis,
thrombocytopenia, hemolytic anemia, neutropenia,
leukopenia, pancytopenia, hepatotoxicity, hypoglycemic
coma
Considerations:
-Know that drug may cause hepatic toxicity at high doses.
-S/s of hepatic toxicity include dark urine, clay-colored
stools; yellowing of skin; abdominal pain; fever or
diarrhea.
-Monitor for hepatic and renal lab values.
-Watch for s/s of chronic poisoning such as rapid, weak
pulse; dyspnea; cold, clammy extremities.
-Monitor pt for s/s of allergic reaction such as rash or
urticaria.
-Monitor for effectiveness through fever reduction or
pain reduction.
-Advise pt that it is unsafe to take more than 4 grams of
acetaminophen in a 24-hr period.
-Instruct pt not to use this med with alcohol.
-Perform teaching on the presence of acetaminophen in
other medications. Instruct pt to take medication with a
full glass of water.
Side effects: headache, fatigue, diarrhea, anorexia,
heartburn, cramps, polyuria, urine acidification,
oxalate/urate renal stones, dysuria, hemolytic anemia
Considerations:
-Assess I&O ratio, urine pH, ascorbic acid levels,
nutritional status, and for thrombophlebitis.
-Teach pt necessary foods to include in diet (i.e. citrus
fruits) and do not exceed prescribed dose.
Side effects: Gastrointestinal ulcer, bleeding, age related
macular degeneration, tinnitus, bronchospasm,
angioedema, Reyes syndrome
Considerations:
-Take medication with a full glass of water (8 ounces or
more) or food.
-Monitor CBC, chemistry profile, BP, fecal occult blood
test, LFTs.
N4810 Clinical Paperwork Rev 11/6/13
-Instruct pt to report s/s of bleeding or GI distress.

- Pt may take with food or milk.

-Instruct pt to avoid alcohol during therapy.

Bisacodyl (Dulcolax)
10 mg suppository daily prn

Calcium carbonate/vitamin D
(caltrate 600+D)
600 mg/400 Unit 2tab PO daily

Laxative; Stimulant
Action: Acts directly in the
intestines by increasing motor
activity; thought to irritate colonic
intramural plexus

Anatacid; calcium supplement

Action: Reduces total acid load in
GI tract, elevates gastric pH to
reduce pepsin activity, strengthens
gastric mucosal barrier, and
increases esophageal sphincter
tone.

Ordered prn to prevent constipation due

to pts limited mobility (intermittently on
restraints due to decreased LOC)

This is used to help with the pts GERD

to reduce acidity level of GI secretions.
Vitamin-D is also for a supplement. This
might be because many patients are being
found to be vitamin D deficient so it is
precautionary in a way.

Side effects: Abdominal colic, abdominal discomfort,

diarrhea, proctitis with suppository use, atony of colon.
Considerations:
-After administration, retain medication for about fifteen
to twenty minutes.
-Monitor for signs of effectiveness such as decreased
abdominal discomfort and pain and a BM within 15 to 60
minutes.
-Reassess pt if recta, bleeding or no BM occurs after 12
hours.
- Perform ot teaching about how drug can cause diarrhea
or abdominal pain, discomfort, and cramping.
-Pts should not take med for more than 7 days unless
approved by a health care professional.
-PR administration: explain procedure to pt, ensure pt
privacy, position pt into sims position , apply clean
gloves, and insert medication gently through anus and
past the internal sphincter and against the rectal wall.
While inserting the medication, tell pt to take slow deep
breaths through the mouth and to relax the anal sphincter.
Side effects: Headache, irritability, weakness, nausea,
constipation, flatulence, rebound hyperacidity
Considerations:
-Know that drug may cause an increase in calcium levels
and may cause a decrease in phosphate levels.
-Record the amount and consistency of stools, and
manage constipation with laxatives or stool softeners.
Monitor calcium levels, especially in pts with mild renal
impairment.
-Calcium should be 8.5-10.5, urine calcium should be
150 mg/day
-Watch for evidence of hypercalcemia such as nausea,
vomiting, headache, confusion and anorexia.
-Perform teaching with patient against taking in an
indiscriminant routine and against switching antacids
without the prescribers advice. Urge pt to notify
prescriber about s/s of GI bleeding such as tarry stools, or
coffee-ground vomitus.

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Clopidogrel (Plavix)
75 mg PO daily

Dextrose (GLUTOSE)
15 g oral gel prn

30 g oral gel prn

Platelet aggregation inhibitor

Action: Inhibits ADP-induced
platelet aggregation. This is for her
peripheral arterial disease, which
works as an anticoagulant.

Action: raises blood glucose

levels. For patients experiencing
acute hypoglycemia. Provides a
source of water and carbohydrates.
The simple carbohydrate may
minimize liver glycogen depletion
and provide protein-sparing action.

Helps reduce the pts future risk of stroke

since she has HTN and a history of
abnormal heart sounds.

For blood glucose of 45-69 mg/dL or

greater if patient is symptomatic, if
patient conscious and able to chew.
This is ordered in case the patient
becomes hypoglycemic again like she
was on admission.
For blood glucose less than 45 mg/dL, if
patient conscious and unable to chew

Side effects: Headache edema, hypertension, chest pain,

constipation, GI bleeding, pancreatitis, hepatic failure,
hypercholestremia, UTI, fatigue, bronchospasm, dyspnea,
bronchitis
Considerations:
-Assess for pt for thrombotic/thrombocytic purpura: fever
thrombocytopenia, neurolytic anemia
-Symptoms of stroke or MI during treatment
-Hepatic studies: AST/ALT bilirubin, creat
-Blood studies: CBC, differential, HCt, Hgb, PT,
cholesterol.
-Teach pt that blood work will be necessary during
treatment. Teach pt to report any unusual
bleeding/bruising and to take the medication with food to
minimize GI upset. Report diarrhea, skin rash, subQ
bleeding, chills, fever, or sore throat. Inform pt to tell all
health care providers that he/she is using this medication.
Side effects: Hyperglycemia, hyperosmolarity, cerebral
hemorrhage, cerebral ischemia, pulmonary edema
Considerations:
-Assess: I&O (make sure patient is receiving adequate
hydration and electrolyte balance)
-Check electrolytes and blood and urine glucose
-Shake well before using

-Same as above
Dextrose 50%
12.5 g IV inj prn

Action: Prevents protein and

nitrogen loss; promotes glycogen
deposition and ketone
accumulation. acute hypoglycemia

For blood glucose of 45-69 mg/dL or

greater if patient is symptomatic. If
patient has an IV and unable to swallow.
This is ordered in case the patient
becomes hypoglycemic again like she
was on admission.

Side effects: Venous thrombosis, heart failure,

hyperosmolar coma, pulmonary edema, hyperglycemia,
hypertension, flushing
Considerations:
-Administer bolus over 5-10 mins
-Infuse concentrations above 10% through central vein.
Do not infuse rapidly, doing so may cause hyperglycemia
and fluid shifts. Never stop infusion abruptly. Monitor
infusion site frequently to prevent irritation, tissue
sloughing, necrosis, and phlebitis.
-Assess: electrolytes and calorie count
-Check blood glucose at regular intervals.
-Monitor I&O. Monitor weight regularly and assess
patient for confusion. Teach pt how to recognize s/s of
hypo and hyperglycemia. And blood glucose monitoring
procedures.
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25 g IV inj prn

For blood glucose less than 45 mg/dL. If

patient has an IV and unable to swallow.

-Administer IV bolus over 5-10 mins

Same as above

-Same as above
Glucagon (Glucagen Hypokit)
1 mg IM inj prn

Same as above

Glucose Chew tab

16 g Chew tab PO prn
32 g Chew tab PO prn

Heparin
5,000 units subQ q12hr

Action: Induces liver glycogen

breakdown and glucose release,
relaxes GI smooth muscle. Raises
blood glucose levels. For patients
experiencing acute hypoglycemia.

Action: raises blood glucose

levels. For patients experiencing
acute hypoglycemia.

Anticoagulant, antithrombotic
-Action: Prevents conversion of
fibrinogen to fibrin and
prothrombin to thrombin by
enhancing inhibitory effects of
antithrombin III

Hydralazine (apresoline)

Antihypertensive, direct-acting
peripheral vasodilator

10 mg IV inj q6hr prn

Action: Vasodilates arteriolar
smooth muscle by direct
relaxation; reduction in blood
pressure with reflex increases heart

For blood glucose of 45-69 mg/dL or

greater if patient is symptomatic. If
unable to obtain IV access and unable to
swallow.

For blood glucose less than 45 mg/dl. If

unable to obtain IV access and unable to
swallow.
For blood glucose of 45-69 mg/dL or
greater if patient is symptomatic.
If patient is conscious and able to
swallow.
For blood glucose less than 45 mg/dL.
If patient is conscious and able to
swallow.
For prevention of DVT due to patients
limited mobility due to restraints ordered
because of the pts altered LOC.

Ordered to lower pts BP because she has

HTN. Acts as a vasodilator thus reducing
pressure within the vessels, lowering BP.
This medication is more of an immediate
actor since it is IV rather than a slower
acting PO medication (which she also has
ordered).

Side effects: Hypotension, hyperglycemia

Considerations:
-Monitor: blood glucose levels and level of
consciousness.
-Teach: Be familiar with technique for administration in
case of emergency, seek medical assistance if no
response is seen within 15 mins of glucagon injection,
once response has occurred patient should be given oral
carbohydrate. This will restore liver glycogen and avoid
recurrence of hypoglycemia,

-Do not swallow whole.

-May administer 4 oz of juice INSTEAD of glucose tabs.

-Do not swallow whole.

-May administer 8 oz of juice INSTEAD of glucose tabs.
Side effects: Fever, chills, headache, hematuria,
hemorrhage, thrombocytopenia, anemia, rash, delayed
transient alopecia, hematoma, cutaneous necrosis,
hyperkalemia, hypoaldosteronism, anaphylaxis
Considerations:
-Assess: bleeding, hemorrhage, blood studies (Hct, occult
blood in stools) q3 months, PTT, platelet count,
hypersensitivity (rash, chills, itching).
-Teach: product may be held during active bleeding. Use
soft bristle toothbrush to avoid bleeding gums, carry
emergency ID, report to prescriber any signs of bleeding
or hypersensitivity
Side effects: Peripheral neuritis, depression, fever,
chills, palpitations, reflex tachycardia, shock, angina.
Rebound hypertension, orthostatic hypotension,
constipation, urinary retention, leukopenia, anemia,
thrombocytopenia, nasal congestion, muscle cramps,
flushing, edema, dyspnea.
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rate, stroke volume, cardiac output

Insulin lispro human

(Humalog KWIKPEN)
Inj Pen 1-6 units subQ tid 30
mins before meals

Magnesium Hydroxide (Milk

of Magnesia)
30 ml oral suspension PO daily
prn

Antidiabetic, pancreatic
hormone; modified structures of
endogenous human insulin

This is used to lower the patients glucose

level due to her Type 2 DM (use sliding
scale)

Action: Decreases blood glucose

by transport of glucose into cells
and the conversion of glucose to
glycogen, indirectly increases
blood pyruvate and lactate,
decreases phosphate and
potassium.

Mineral; Antacid
Action: Increases osmotic
gradient in small intestine, which
draws water into intestines and
causes distention. These effects
simulate peristalsis and bowel
evacuation.

This is ordered prn in order to prevent

constipation as a result of the patients
limited mobility form restraints.

Considerations:
-For IV administration: each 10 mg over 1 minute
-DBP> 95
-SBP>165
-Assess: cardiac status, electrolytes (K, Na, Cl, CO2,
CBC, glucose. Weight daily, edema, crackles, dyspnea,
orthopnea. IV site for extravasation. Mental status,
-Teach: to take with food, avoid OTC preps. Notify
prescriber if chest pain, severe fatigue, fever, muscle or
joint pain
Rise slowly
Side effects: Blurred vision, dry mouth, flushing,
lipodystrophy, lipohypertrophy, swelling, hypoglycemia,
rebound hyperglycemia, peripheral edema
Considerations:
-Sensitive regimen
-Dont hold if NPO
-Give the following correction insulin in addition to any
nutritional insulin.
-For blood glucose:
70-200 mg/dL: 0 units
201-250 mg/dL: 2 units
251-300 mg/dL: 3 units
301-350 mg/dL: 4 units
351-400 mg/dL: 5 units
Greater than 400 mg/dL, draw serum blood glucose,
administer 6 units and notify prescriber
-Assess: fasting blood glucose, A1c, urine ketones,
hypoglycemic reaction (sweating, weakness, dizziness,
confusion, headache, rapid weak pulse, fatigue,
tachycardia, slurred speech, staggering gait, acetone
breath, hunger
-Teach: keep insulin equipment available at all times
(carry a glucagon kit, candy or lump of sugar), does not
sure diabetes, carry emergency ID as diabetic, recognize
hypoglycemia reactions (headache, tremors, fatigue,
weakness) and hyperglycemia (frequent urination, thirst,
fatigue, hunger). Symptoms of ketoacidosis (polyuria, dry
mouth, increased BP, acetone breath, Kussmaul
Side effects: Confusion, decreased reflexes, dizziness,
syncope, paralysis, hypothermia, hypotension,
arrhythmias, circulatory collapse, nausea, vomiting,
cramps, flatulence, anorexia, hypermagnesemia,
hypocalcemia, muscle weakness, diaphoresis, allergic
reaction
Considerations:
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Magnesium Sulfate
2g in water in 50 ml IVPB
(premix) prn

Electrolyte, anticonvulsant,
saline laxative, antacid
Action: Increases osmotic
pressure, draws fluid into the
colon, neutralizes HCl

For electrolyte replacement. The pts Mg

level has been intermittently low which
could possibly be due to malnutrition
caused decreased food intake because of
confusion and being placed on restraints.

-Shake well before using

-Follow dose with full glass of water.
-Assess for the cause of constipation. Perform pt
teaching about adverse reactions. Know that this
medication may delay absorption of other drugs. Instruct
pt that prolonged use of this medication can lead to
laxative dependence. Perform teaching on how a healthy
diet and regular exercise can reduce the need for
laxatives. Monitor electrolyte and liver function tests
while administering this medication. Monitor I&O.
Continue to monitor for medication effectiveness by
assessing the abdomen (looks, listen, feel) and asking the
pt regularly about BMs.
Side effects: muscle weakness, sweating. Confusion
flaccid paralysis, hypothermia, hypotension, heart block,
circulatory collapse, vasodilation, diarrhea, prolonged
bleeding time, electrolyte, fluid imbalances, respiratory
depression/paralysis
Considerations:
-Mg between 1.5-1.8 mg/dL
-Refrigerate
-Watch patient for s/s of magnesium toxicity: thirst,
confusion, decrease in reflexes, I&O ration, check for
decrease in urinary output
-Teach pt the reason for administration and expected
results.
-Mg between 1.2-1.4 mg/dL
-Refrigerate

3g in dextrose 5% 100 ml IVPB

prn

Mg between 0.9-1.1 mg/dL

4g in sterile water 100 mL

Metoprolol tartrate
(Lopressor)
50 mg tab PO bid

Beta-adrenergic blocker;
cardiovascular agent
Action: Selective activity on beta1 adrenoreceptors located mainly
in cardiac muscles. At higher
doses, it may inhibit beta-2
adrenoreceptors of bronchial and
vascular smooth muscles. Possible
mechanisms of antihypertension
effects include: competitive
antagonism of catecholamines at

Given to this pt to lower her BP because

she has a history of HTN. However, this
medication ended up being d/c because
her heart rate would drop rapidly after
administration and then sky rocket again
in the 100s after the medication wore off.
The doctors suspected sick sinus
syndrome (SSS) as the cause.

Side effects: Bronchospasm, bradyarrhythmia, heart

block, heart failure, hypotension, constipation, diarrhea,
nausea, dizziness, headache, depression, dyspnea.
Considerations:
-Hold for systolic blood pressure less than 90 or heart rate
less than 60
Instruct pt to take with or immediately following meals.
Swallow tab whole with glass of water.
-Monitor BP regularly and especially near the end of the
dosing interval to confirm 24-hr hypertension control.
-Monitor BP, HR and ECG in early treatment to assess
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peripheral and cardiac adrenergic

receptors, a central effect leading
to reduced sympathetic outflow,
and suppression of rennin activity.

Potassium chloride
10 mEq in sterile water 100ml
IVPB premix daily prn

Electrolyte/mineral replacement;
potassium
-Action: Needed for the adequate
transmission of nerve impulses and
cardiac contraction, renal function,
intracellular ion maintenance

Potassium chloride CR
(KCOR-CON, KDUR)

Mineral and electrolyte

replacement; supplement

10-40 mEq PO daily prn

-Action: Maintain acid-base

balance, isotonicity, and
electrophysiologic balance of the
cell, activator in many enzymatic
reactions, transmission of nerve
impulses, contraction of cardiac,
skeletal and smooth muscle.

In case of hypokalemia The patients

levels were actually high on admission,
but then remained WNL the following
days. This must have been ordered as a
precaution on the doctors part due to pts
age and possible malnutrition resulting
from decreased/altered LOC.

Same as above (just in PO form)

for MI. Regularly monitor HR and rhythm during

therapy.
-Teach pt to avoid of activities requiring coordination
until drug effects are realized. Advise pt to report s/s of
cardiac failure such as pulmonary edema, dyspnea,
cyanosis, peripheral edema, hepatomegaly. Be aware that
durg may mask s/s of hypoglycemia. Advise pt to take
ER tabs after meals.
-DO NOT ABRUPTLY STOP TAKING MED. The
dosage should be gradually reduced over a period of 1 to
2 weeks.
Side effects: Confusion, bradycardia, cardiac depression,
dysrhthymias, and arrest, pain, diarrhea, ulceration of
small bowel, oliguria, cold extremities
Considerations:
->3.5 NO replacement
-Potassium 3.1-3.4-administer KCL 10 mEq in 100 mL
sterile water over 1 to 2 hours.
-Potassium 3.0 or below administer KCL 10 mEq in 100
mL sterile water over 1 hour in 4 divided doses. If patient
is NPO or not able to tolerate PO
-<2.9 KCl 10mEq in 100 ml steril water over 1-4 hrs plus
coadminister 40 mEq po dose
-Document each KCl replacement does seperatley on
eMAR
-Use peripheral or central line
-Notify physician if >80 mEq of KCl/ 24hr is
administered
-Administer dose if creatinine less than or equal to 2.0
-Assess hyperkalemia, potassium level, hydration status,
I& ratio, cardiac status
-Teach pt to add potassium rich food to their diet, avoid
OTC, report hyperkalemia/hypokalemia symptoms
(lethargy, confusion, decreased output), dissolve powder
or tablet completely,
Side effects: Arrhythmias, heart block, cardiac arrest,
hyperkalemia, respiratory paralysis
Considerations:
Potassium replacement scale:
3.5-4.0= 20 mEq KCl po once
3.0-3.4= 40 mEq KCl po once
less than or equal to 2.9= 40 mEq po once with 40 mEq
IV
-Administer dose if creatinine less than or equal to 2.0
-Dont crush/ chew and take with food
Document each KCl replacement does separately on
N4810 Clinical Paperwork Rev 11/6/13

eMAR
-Monitor vital signs and ECG. Do not administer drug if
apical pulse or BP is low. Particular caution must be
used in the administration of K-Dur to this pt because she
has a first degree heart block and potassium supplements
can cause heart block. Monitor renal function and check
BUN and creatinine labs often. Pay careful attention to
potassium lab values and monitor daily. DO NOT
ADMINISTER MED IF POTASSIUM LEVELS ARE
GREATER THAN NORMAL. Educate pt on ways to
consume potassium through their diet by eating leafy
greens, avocado, bananas, potatoes, and beans.
Pravastatin (pravachol)

Antilipemic; HMG-CoA
reductase enzyme

80 mg tab po daily
Action: Inhibits HMG-CoA
reductase enzyme which reduces
cholesterol synthesis

Risperidone (Risperdal)

Antipsychotic
Benzisoxazole derivative

0.25 mg tab po daily

Action: Unknown; May mediate
through both dopamine and
serotonin antagonism.

For patients history of hyperlipidemia. It

helps reduce the levels of LDL and
triglycerides in the blood, while
increasing the levels of HDLs.

Used to treat patients confusion and

altered LOC. It was working for the first
couple of days, however, the doctor d/c it
because it was causing pauses in the
patients cardiac rhythm.

Side effects: fatigue, chest pain, constipation, diarrhea,

abdominal pain, heartburn, hepatic dysfunction,
pancreatitis, hepatitis, renal failure, myalgia, rhinitis,
cough
Considerations:
-Assess fasting lipid profile (LDL, HDL, triglycerides),
hepatic studies (AST, ALT, LFTs may increase), renal
studies (BUN, I&O ratio, creatnine), rhabdomyolysis
(muscle tenderness and pain).
-Teach that blood work will be necessary during
treatment. Teach patient to report blurred vision, sever GI
symptoms, muscle pain, weakness, and fever. Pt should
follow low cholesterol diet and an exercise program
-Side effects: EPS, dystonia, tardive dyskinesia,
insomnia, drowsiness, seizures, neuroleptic malignant
syndrome, suicidal ideation, orthostatic hypotension,
tachycardia, heart failure, constipation, jaundice, weight
gain, hyperprolactinemia, neutropenia, upper respiratory
infection
Considerations:
-Assess for suicidal thoughts/behaviors. Make sure the
patient swallowed the medication
-Assess I&O, bilirubin, CBC, hepatic studies, urinalysis,
affect, orientation, LOC, reflexes, and sleep pattern.
-Monitor pts B/P for s/s of dizziness, faintness,
palpitations, tachycardia, EPS, and neuroleptic malignant
syndrome. Assess for constipation, urinary retention,
weight gain, hyperglycemia, and metabolic changes.
-Teach the pt that orthostatic hypotension may occur;
avoid hot tubs, abrupt withdrawal from medication, OTC
preparations, and hazardous activities. Teach the pt to
comply with medications and to notify the prescriber
immediately if suicidal thoughts/behaviors occur.
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