NURSING PROCESS

PATIENT RECEIVING VASOPRESSIN

ASSESSMENT

Preadministration Assessment

Patients experiencing diabetes insipidus process large amounts of fluid in their bodies. To assess drug response the weight, vital signs, and a patient history of fluid intake and output are taken. Serum electrolyte levels and other laboratory tests may be ordered by the primary health care provider.

Before administering vasopressin to relieve abdominal distention, document the patient’s blood pressure, pulse, and respiratory rate. Auscultate the abdomen and record the findings. Additionally, measure and document the patient’s abdominal girth.

Ongoing Assessment

During the ongoing assessment of a hospitalized patient, monitor the blood pressure, pulse, and respiratory rate every 4 hours or as ordered by the primary health care provider. The patient’s fluid intake and output are strictly measured. The primary health care provider is notified if there are any significant changes in these vital signs, because a dosage adjustment may be necessary.

The dosage of vasopressin or its derivatives may require periodic adjustments. After administration of the drug, observe the patient every 10 to 15 minutes for signs of an excessive dosage (e.g., blanching of the skin, abdominal cramps, and nausea). If these occur, reassure the patient that recovery from these effects will occur in a few minutes.

NURSING DIAGNOSES

Drug-specific nursing diagnoses include the following:

  Deficient Fluid Volume related to inability to replenish fluid intake secondary to diabetes insipidus

  Acute Pain related to abdominal distention

Nursing diagnoses related to drug administration are discussed in Chapter 4.

PLANNING

The expected outcomes for the patient may include an optimal response to therapy, support of patient needs related to the management of adverse reactions, and confidence in an understanding of the medication regimen.

IMPLEMENTATION

Promoting an Optimal Response to Therapy

Vasopressin may be given intramuscularly (IM) or subcutaneously (subcut) to an inpatient to treat diabetes insipidus. To prevent or relieve abdominal distention, the first dose is given 2 hours before x-ray examination and the second dose 30 minutes before the testing. An enema may be given before the first dose.

Desmopressin may be given orally, intranasally, subcut, or intravenously (IV). When the condition becomes chronic and the patient learns to self-administer the drug, adjustments are made according to the patient’s response to therapy. Patients learn to regulate their dosage based on the frequency of urination and increase of thirst. A higher dose of the drug may be taken at night to reduce thirst and urination while sleeping.

Monitoring and Managing Patient Needs

The adverse reactions associated with vasopressin, such as skin blanching, abdominal cramps, and nausea, may be decreased by administering the agent with one or two glasses of water. If these adverse reactions occur, inform the patient that they are not serious and should subside within a few minutes.

  NURSING ALERT

Excessive dosage is manifested as water intoxication (fluid overload). Symptoms of water intoxication include drowsiness, listlessness, confusion, and headache (which may precede convulsions and coma). If signs of excessive dosage occur, notify the primary health care provider before the next dose of the drug is due; a change in the dosage, the restriction of oral or IV fluids, and the administration of a diuretic may be necessary.

DEFICIENT FLUID VOLUME. The symptoms of diabetes insipidus include the voiding of a large volume of urine at frequent intervals during the day and throughout the night. Accompanying this frequent urination is the need to drink large volumes of fluid, because patients with diabetes insipidus are continually thirsty and need to be supplied with large amounts of drinking water. Take care to refill the water container at frequent intervals. This is especially important when the patient has limited ambulatory activities. Until controlled by a drug, the symptoms of frequent urination and excessive thirst may cause a great deal of anxiety. Reassure the patient that with the proper drug therapy, these symptoms will most likely be reduced or eliminated.

Fluid intake and output are accurately measured and the patient is observed for signs of dehydration (dry mucous membranes, concentrated urine, poor skin turgor, flushing, dry skin, confusion). This is especially important early in treatment and until such time as the optimum dosage is determined and symptoms have diminished. If the patient’s output greatly exceeds intake, contact the primary health care provider. In some instances, the primary health care provider may order specific gravity and volume measurements of each voiding or at hourly intervals. Document these results in the chart to aid the primary health care provider in adjusting the dosage to the patient’s needs.

CHRONIC CARE CONSIDERATIONS

If a person with diabetes insipidus is unable to take routine medication, a fluid deficit can rapidly occur. Therefore, individuals with diabetes insipidus should wear a medical alert bracelet so emergency personnel can be aware of this need for the medication and dosing can be continued if the patients are unable to take the drug themselves.

ACUTE PAIN. If the patient is receiving vasopressin for abdominal distention, explain the details of treating this problem and the necessity of monitoring drug effectiveness (e.g., auscultation of the abdomen for bowel sounds, insertion of a rectal tube, and measurement of the abdomen). If a rectal tube is ordered after administration of vasopressin for abdominal distention, the lubricated end of the tube is inserted past the anal sphincter and taped in place. The tube is left in place for 1 hour or as prescribed by the primary health care provider. Auscultate the abdomen every 15 to 30 minutes and measure abdominal girth hourly, or as ordered by the primary health care provider.

Educating the Patient and Family

If desmopressin is to be used nasally, ensure that the patient masters the technique of instillation. Provide illustrated patient instructions with the drug and review them with the patient. You should discuss the need to take the drug as directed by the primary health care provider. The patient should change the dosage (i.e., the prescribed number or frequency of sprays) only after consulting with the primary health care provider.

Emphasize the importance of adhering to the prescribed treatment program to control symptoms. In addition to instruction in administration, include the following in a patient and family teaching plan:

  Wear medical identification naming the disease and the drug regimen.

  Carry a sport drink bottle to be sure to have liquids available at all times.

  Monitor the amount of fluids taken each day.

  Monitor the amount and frequency of urine for each 24-hour period, reporting changes to daily patterns to your nurse.

  Carry extra doses of the drug in case you do not make it home in time for your next dose.

  Avoid the use of alcohol while taking these drugs.

  Rotate injection sites for parenteral administration.

  Contact the primary health care provider immediately if any of the following occurs: a significant increase or decrease in urine output, abdominal cramps, blanching of the skin, nausea, signs of inflammation or infection at the injection sites, confusion, headache, or drowsiness.

EVALUATION

  Therapeutic effect is achieved.

  Adverse reactions are identified, reported to the primary health care provider, and managed successfully through appropriate nursing interventions:

  Patient and family express confidence and demonstrate an understanding of the drug regimen.

NURSING PROCESS

PATIENT RECEIVING VASOPRESSIN

ASSESSMENT

Preadministration Assessment

These drugs are almost always administered on an outpatient basis and may be self-administered by the patient. Before prescribing any of these drugs, the primary health care provider takes a thorough medical history and performs a physical examination. Additional laboratory and diagnostic tests for ovarian function and tubal patency may also be performed. A pelvic examination may be performed by the primary health care provider to rule out ovarian enlargement, pregnancy, or uterine problems.

Ongoing Assessment

At the time of each office or clinic visit, ask the patient about the occurrence of adverse reactions and document the patient’s vital signs and weight.

NURSING DIAGNOSES

Drug-specific nursing diagnoses include the following:

  Acute Pain related to adverse reactions (ovarian enlargement, irritation at the injection site)

  Anxiety related to inability to conceive, treatment outcome, other factors

Nursing diagnoses related to drug administration are discussed in Chapter 4.

PLANNING

The expected outcomes of the patient may include an optimal response to drug therapy, support of patient needs related to the management of adverse reactions, reduction in anxiety, and confidence in an understanding of the medication regimen.

IMPLEMENTATION

Promoting an Optimal Response to Therapy

Gonadotropin injections are given in the primary health care provider’s office or the clinic or may be self-administered. These drugs must be administered IM or subcut because they are destroyed in the gastrointestinal (GI) tract; therefore, they cannot be taken orally. Injection sites are rotated and previous sites are checked for redness and irritation.

  NURSING ALERT

If the patient complains of visual disturbances, the drug therapy is discontinued and the primary health care provider notified. An examination by an ophthalmologist is usually indicated.

Monitoring and Managing Patient Needs

Acute Pain. Female patients taking these drugs are usually examined by the primary health care provider frequently to detect excessive ovarian stimulation, called hyperstimulation syndrome (sudden ovarian enlargement with ascites). The patient may or may not report pain. This syndrome usually develops quickly, within 3 to 4 days.

  NURSING ALERT

The patient is checked for signs of excessive ovarian enlargement (abdominal distention, pain, ascites [with serious cases]). The drug is discontinued at the first sign of ovarian stimulation or enlargement. The patient is usually admitted to the hospital for supportive measures.

ANXIETY. Patients seeking treatment to become pregnant often experience a great deal of anxiety due to past failed attempts. In addition, when taking these drugs, the patient faces the possibility of multiple births. The success rate of these drugs varies and depends on many factors. The primary health care provider usually discusses the value of this, as well as other approaches, with the patient and her sexual partner. Allow the patient time to talk about her concerns about the proposed treatment program.

Educating the Patient and Family

Patients are instructed by the primary health care provider about the frequency of sexual intercourse. You can assess whether the patient understands the directions given by the primary health care provider. When a gonadotropin is prescribed, you may instruct the patient how to use the device to inject the hormone and to keep all primary health care provider appointments and to report adverse reactions to the nurse or primary health care provider. Include the following information when a gonadotropin is prescribed:

HORMONAL OVARIAN STIMULANTS

  Before beginning therapy, be aware of the possibility of multiple births and birth defects.

  It is a good idea to use a calendar to track the treatment schedule and ovulation.

  Report bloating, abdominal pain, flushing, breast tenderness, and pain at the injection site.

NONHORMONAL OVARIAN STIMULANTS

  Take the drug as prescribed (5 days) and do not stop taking the drug before the course of therapy is finished unless told to do so by the primary health care provider.

  Notify the primary health care provider if bloating, stomach or pelvic pain, jaundice, blurred vision, hot flashes, breast discomfort, headache, nausea, or vomiting occurs.

  Keep in mind that if ovulation does not occur after the first course of therapy, a second or third course may be used. If therapy does not succeed after three courses, the drug is considered unsuccessful and is discontinued.

EVALUATION

  Therapeutic effect is achieved.

  Adverse reactions are identified, reported to the primary health care provider, and managed successfully through appropriate nursing interventions:

   •  Patient is free of pain.

   •  Anxiety is managed successfully.

  Patient expresses confidence and demonstrates an understanding of the drug regimen.