(This section helps the nurse apply the nursing process to pharmacotherapeutics. The subsections provide a step-by-step guide to clinical assessment, implementation (Contraceptives administration), and evaluation of the outcomes of pharmacologic therapy.)
(This section includes guidelines for assessing patient history and physical data before and during drug therapy. Assessments specific to the drug’s various indications are also included.)
• Assess blood pressure before and periodically during therapy.
• Acne: Assess skin lesion before and periodically during therapy.
• Lab Test Considerations: Monitor hepatic function periodically during therapy.
• Estrogens only — Contraceptives may cause increase serum glucose, sodium, triglyceride, VHDL, total cholesterol, prothrombin, and factors VII, VIII, IX, and X levels. Contraceptives may cause reduce IDL and antithrombin III levels.
• May cause false interpretations of thyroid function tests.
• Progestins only — Contraceptives may cause increase low-density lipoproteins (LDL) concentrations. Contraceptives may cause reduce serum alkaline phosphatase and high-density lipoproteins (HDL) concentrations.
Potential Nursing Diagnoses
(The two or three most pertinent NANDA diagnoses that potentially apply to a patient receiving the Contraceptives are listed. Each diagnosis includes the pharmacologic effect from which the diagnosis has been derived.)
Noncompliance (Patient/Family Teaching)
(Guidelines specific for Contraceptives administration)
• Per Os/By Mouth: Oral doses may be administered with or immediately after food to reduce nausea. Chewable tablets may be swallowed whole or chewed; if chewed follow with 8 ounces of liquid.
• For extended-cycle tablets, Seasonale or Seasonique — take active tablets for 84 days and followed by the placebo tablets for 7 days; for Lybrel — Take 1 pill each day for 28 days, then start the next set of pills daily for the next 28 days.
• Subcut: Shake vigorously before use to form a uniform suspension. Inject slowly (over 5-7 seconds) at a 45° angle into fatty area of anterior thigh or abdomen every 12 to 14 weeks. If more than 14 weeks elapse between injections, rule out pregnancy prior to administration. Do not rub area after injection.
• When switching from other hormonal contraceptives, administer within dosing period (7 days after taking last active pill, removing patch or ring, or within the dosing period for intramuscular injection).
• Intramuscular (IM): Shake vial vigorously just before use to ensure uniform suspension. Administer deep intramuscular into gluteal or deltoid muscle. If period between injections is > 14 wk, determine that patient is not pregnant before administering the drug.
• In j ectable medroxyprogesterone may lead to bone loss, especially in women younger than 21 years. In j ectable medroxyprogesterone should be used for > 2 years only if other methods of contraception are inadequate. If used long term, women should use supplemental calcium and vitamin D, and monitor bone mineral density.
Contraceptives: Patient/Family Teaching
(This section includes information that should be taught to patients. Side effects that should be reported, information on minimizing and managing side effects of Contraceptives, details on administration, and follow-up requirements are presented. Home Care Issues discusses aspects to be considered for medications taken in the home setting.)
• Instruct patient to take oral medication as directed at the same time each day. Pills should be taken in proper sequence and kept in the original container. Advise patient not to skip pills even if not having sex very often.
• If single daily dose is missed: Take as soon as remembered; if not until next day, take 2 tablets and continue on regular dosing schedule. If 2 days in a row are missed: Take 2 tablets a day for the next 2 days and continue on regular dosing schedule, using a second method of birth control for the remaining cycle. If 3 days in a row are missed: Discontinue medication and use another form of birth control until period begins or pregnancy is ruled out; then begin a new cycle of tablets. For 28-day dosing schedule: If schedule is followed for first 21 days and 1 dose is missed of the last 7 tablets, it is important to take the 1 st tablet of next month’s cycle on the regularly scheduled day.
• Advise patient taking Seasonale or Sesonique extended-cycle tablets that withdrawal bleeding should occur during the 7 days following discontinuation of the active tablets. If withdrawal bleeding does not occur, notify health care professional. Advise patient taking lybrel that no withdrawal bleeding should occur.
• For initial use of Seasonale or Seasonique extended cycle tablets, caution patient to use a nonhormonal method of contraception until she has taken the first 7 days of active tablets. Each 91-day cycle should start on the. same day of the week. If started later than the proper day or 2 or more days are missed, a second nonhormonal method of contraception should be used until she has taken the pink tablet for 7 days. Transient spotting or bleeding may occur. If bleeding is persistent or prolonged, notify health care professional.
• Advise patient taking extended cycle tablets that spotting or light bleeding may occur, especially during first 3 months. Continue medication; notify health care professional if bleedinglasts >7 days.
• Advise patient of the need to use another form of contraception for the first 3 week when beginning to use oral contraceptives.
• Advise patient that a second method of birth control also should be used during each cycle in which any of the following are used: Oral contraceptives — ampicillin, corticosteroids, antiretroviral protease inhibitors, barbiturates, carbamazepine, chloramphenicol, dihydroergotamine, corticosteroids (systemic), mineral oil, oral neomycin, oxcarbazapine, penicillin V, phenylbutazone, primidone, rifampin, sulfonamides, tetracyclines, topiramate, orvalproic acid.
• Explain dose schedule and maintenance routine. Discontinuing medication suddenly may cause withdrawal bleeding.
• If nausea becomes a problem, advise patient that eating solid food often provides relief. If nausea persists or vomiting or diarrhea occur, use a nonhormonal method of contraception and notify health care professional.
• Advise patient to report signs and symptoms of fluid retention (swelling of ankles and feet, weight gain), thromboembolic disorders (pain, swelling, tenderness in extremities, headache, chest pain, blurred vision), mental depression, hepatic dysfunction (yellowed skin or eyes, pruritus, dark urine, light-colored stools), or abnormal vaginal bleeding. Women with a strong family history of breast cancer, fibrocystic breast disease, abnormal mammograms or cervical dysplasia should be monitored for breast cancer at least yearly.
• Instruct patient to stop taking medication and notify health care professional if pregnancy is suspected.
• Caution patient that cigarette smoking during estrogen therapy may increase risk of serious side effects, especially for women over age 35.
• Caution patients to use sunscreen and protective clothing to prevent increased pigmentation.
• Caution patient that oral contraceptives do not protect against HIV or other sexually transmitted diseases.
• Advise patient to notify health care professional of medication regimen before treatment or surgery.
• Emphasize the importance of routine follow-up physical exams including blood pressure; breast, abdomen, and pelvic examinations; and Papanicolaou smears every 6-12 month.
• intramuscular (IM), Subcut Advise patient to maintain adequate amounts of dietary calcium and vitamin D to help prevent bone loss.
• Transdermal: Instruct patient on application of patch. First patch should be applied within 24 hourss of menstrual period. If applied after day 1 of menstrual period, a nonhormonal method of contraception should be used for the next 7 days. Day of application becomes Patch Change Day. Patches are worn for 1 week and changed on the same day of each week for 3 weeks. Week 4 is patch-free. Withdrawal bleeding is expected during this time.
• Apply patch to clean, dry, intact, healthy skin on buttock, abdomen, upper outer arm, or upper torso in a place where it won’t be rubbed by tight clothing. Do not place on skin that is red, irritated, or cut, and do not place on breasts. Do not apply make-up, creams, lotions, powders, or other topical products to area of patch application.
• To apply patch open foil pouch by tearing along edge using fingers. Peel pouch apart and open flat. Grasp a corner of the patch firmly and remove gently from foil pouch. Use fingernail to lift one corner of the patch and peel patch and the plastic liner off the foil liner. Do not remove clear liner as patch is removed. Peel away half of the clear liner without touching sticky surface. Apply the sticky surface and remove the rest of the liner. Press down firmly with palm of hand for 10 seconds; make sure the edges stick well.
• On Patch Change Day remove patch and apply new one immediately. Used patch still contains some active hormones; fold in half
so it sticks to itself and throw away. Apply new patches to a new spot to prevent skin irritation; may be applied in same anatomic area.
• Following patch-free week, apply a new patch on Patch Change Day, the day after Day 28, no matter when the menstrual cycle begins.
• If patch becomes partially or completely detached for less than 1 day, reapply patch or apply new patch. If patch is detached for more than 1 day, apply a new patch immediately and use a nonhormonal form of contraception for the next 7 days. Cycle will now start over with a new Patch ChangeDay. If patch is no longer sticky, apply a new patch; do not use tape or wraps to keep patch in place.
• If patch is not changed on Patch ChangeDay in the first week of the cycle, apply new patch immediately upon remembering and use a nonhormonal method of contraception for next 7 days. If patch change is missed in for 1 or 2 days during Week 2 or 3, apply new patch immediately and apply next patch on usual Patch ChangeDay. No backup contraception is needed. If patch change is missed for more than 2 days during Week 2 or 3, stop the cycle and start a new 4-wk contraceptive cycle by applying new patch immediately and using a nonhormonal method of contraception for the next 7 days. If patch is not removed on Patch ChangeDay in Week 4, remove as soon as remembered and start next cycle on usualPatch ChangeDay. No additional contraception is needed.
• NuvaRing: If a hormonal contraceptive was not used in the past month, insert NuvaRing between Days 1 and 5 of the menstrual cycle (Day 1 = first day of menstrual period), even if bleeding has not finished. Use a nonhormonal method of birth control other than a diaphragm during the first 7 days of ring use. If switching from a combination estrogen/progesterone oral contraceptive, insert NuvaRing any time during first 7 days after last tablet and no later than the day a new pill cycle would have started. No extra birth control is needed. If switching from a min reduce-pill, start using NuvaRing on any day of the month; do not skip days between last pill and first day of NuvaRing use. If switching from an implant, start using NuvaRing on same day implant is removed. If switching from an injectable contraceptive, start using NuvaRing on the day when next injection is due. If switching from a progestin-containing IUD, start using NuvaRing on the same day as IUD is removed. A nonhormonal method of contraception, other than the diaphragm, should be used for the first 7 days of NuvaRing use when switching from the mini-pill, implant, injectable contraceptive, or IUD.
• NuvaRing comes in a reclosable foil pouch. Instruct patient to wash hands, then remove NuvaRing from pouch; keep pouch for ring disposal. Using the position of comfort (lying down, squatting, or standing with one leg up), hold NuvaRing between thumb and index finger and press opposite sides of the ring together. Gently push folded ring into vagina. Exact position is not important for function of NuvaRing. Most women do not feel Nuva-Ring once it is in place. If discomfort is felt, NuvaRing may not be inserted far enough into vagina; use finger to push further into vagina. There is no danger of NuvaRing being pushed in too far or getting lost. Once inserted, leave NuvaRing in place for 3 weeks.
• Remove ring 3 weeks after insertion on same day and time of insertion. Remove by hooking finger under forward rim or by holding ring between index and middle finger and pulling out. Place ring in foil pouch and dispose; do not throw in toilet. Menstrual period will usually start 2-3 days after ring is removed and may not have finished before next ring is inserted. To continue contraceptive protection, new ring must be inserted 1 week after last one was removed, even if menstrual period has not stopped.
• If NuvaRing slips out of vagina and has been out less than 3 hourss, contraceptive protection is still in place. NuvaRing can be rinsed in cool to tepid water and should be reinserted as soon as possible. If ring is lost, insert a new ring and continue same schedule as lost ring. If NuvaRing has been out of vagina for more than 3 hourss, a nonhormonal method of contraception, other than a diaphragm, should be used for the next 7 days.
• If NuvaRing has been left in for an extra week or less (4 weeks total or less), remove and insert a new ring after a 1 -wk ring-free break. If NuvaRing has been left in place for more than 4 weeks, woman should check to be sure she is not pregnant. A nonhormonal method of contraception, other than a diaphragm, must be used for the next 7 days.
Contraceptives: Evaluation / Desired Outcomes
(Outcome criteria for determination of the effectiveness of Contraceptives are provided.)
• Prevention of pregnancy.
• Regulation of the menstrual cycle.
• Decrease in acne.
• Decrease in symptoms of premenstrual dysphoric disorder.