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Policy #510

COALINGA STATE HOSPITAL
NURSING POLICY AND PROCEDURE MANUAL
SECTION - Medications
POLICY NUMBER: 510
Effective Date: August 31, 2006
SUBJECT: CARE OF THE INDIVIDUAL RECEIVING CLOZAPINE

1. GENERAL:

Clozapine is indicated for the severely ill schizophrenic Individual who has not responded to other neuroleptic medication or who is experiencing intolerable side effects from current medication. During the stabilization, period Individuals will be titrated up from an initial low dose. Because of potentially severe blood dyscrasias, Pharmacy will only distribute unit dose supplies based on mandatory weekly or bi-weekly white blood counts (WBCs). Due to the effect of clozapine on the GI tract, special consideration must be given when assessing the Individual for potential or actual constipation. A Individual may be constipated or have a partial impaction with no symptoms, or subtle symptoms. Nursing is required to assess any change in Individual status that may indicate constipation or formation of an impaction. The following changes in a Individual’s status can indicate the beginning of an impaction: changes in mental status (e.g. confusion, delirium); an increase in the Individual’s presenting psychiatric or psychotic symptoms; physical changes such as bloating, discomfort or pain in the abdomen or rectum. If changes are found upon assessment, the change in status must be referred to the physician immediately. Though some Individuals on clozapine have had no difficulty with constipation, each Individual will be monitored by eliminative subsystem each shift.
2. PURPOSE:

To assure that clozapine is administered safely and in a manner that minimizes risk from potential untoward reactions.
3. PROCEDURE:

NURSING ACTION
RATIONALE-PRECAUTIONS
A. All Individuals on clozapine will have a
A. Individual will be evaluated and
associated with clozapine with special emphasis on constipation. B. Obtain a physician's order for baseline
B. Ongoing monitoring of the Individual
for potential adverse reactions requires adequate baseline information to interpret changes. C. The physician will receive a start-up
C. Pharmacy will not dispense the
baseline data is completed or current by: -Lab
Within 30 days: WBC
Within previous year:
- Serum creatinine
- Electrolytes
- Liver function panel
- Total protein
- Albumin
- Urinalysis
-30 days prior to starting, a complete
physical assessment including:
- abdominal and rectal exam
- KUB
-EKG - Within previous year
D. Complete set of Vital signs twice
daily for 3 days.
E.
E. If constipation is present or part of
the Individual's history, the problem must be resolved/treated before clozapine therapy is instituted. F. Nutrition Services has a vital role in
referral will be sent to Nutrition Services nutritional intake and prevention of constipation A. The initial dose of medication will
not be distributed until the pre-treatment procedures and forms are completed and the clozapine registry has been contacted and an authorization number has been received. Physician’s orders must also be sent to the pharmacy.
B. To obtain subsequent doses of the
medication, bring a copy of the
physician's orders.
C. Return to the Pharmacy any pills
C. All doses must be accounted for.
left over after the dosing period.
D. If new orders are written and/or the
current, on-hand supply is insufficient,
bring the remaining doses back to
Pharmacy with the most current
orders and new medication will be
dispensed.
E. If the Individual refuses a dose
and/or a dose needs to be wasted,
notify Pharmacy so that additional
doses can be dispensed.
F. If Pharmacy is closed and it is
F. To assure there is no interruption of
A. Obtain a physician's order for weekly
A. Agranulocytosis may occur and is a
WBC’s with differential for the first 6 with differential after the first 6 months (weekly or bi-weekly will be determined
by the physician after the first 6 months
of treatment). Monthly KUB times three
months and then quarterly thereafter.
B. Write "WCB with DIFF. for Clozapine"
B. Laboratory personnel must be notified
in the box labeled "test requested" on on the lab slip that the Individual is being C. Schedule the Individual to have a
C. To avoid duplicate or unnecessary
needle punctures. The lab can obtain all the needed samples with a single puncture. D. If the routine lab day falls on a
D. The lab is closed on all state holidays
E. If the WBC falls below 3500, labs will be
E. If the WBC reveals a significant drop in
cell count, even if WBC count is still in or more consecutive drops in WBC cell counts the Individual needs closer monitoring for potential infection. F. If the WBC drops below 3000,
F. To reduce and prevent infection in a
drops below 2000, the Individual will be admitted to the Infirmary Unit for reverse isolation D. Ongoing Nursing Care of the Individual on Clozapine: A. One hour after the first dose then
A. Monitoring vital signs when initiating
clozapine is important since side effect such as hypotension, tachycardia, and fever may occur. Special consideration needs to be given to Individuals who may also be on a benzodiazepine due to possible respiratory collapse or hypotension. B. Report fever or sore throat to
B. These are frequently the first signs of
A. Monitor weekly or bi-weekly WBC with
A. Agranulocytosis may occur in
differential. Assist the Individual to keep Individuals receiving clozapine. Liver and function panels are required every six (6)
months. Serum creatinine levels are
done at the 3rd and 6th months, then
every 6 months thereafter.
B. Reinforce with the Individual the
B. To prevent infection in a Individual
measures (hand hygiene, not sharing cups, etc.). C. Educate Individual regarding fluid
C. To prevent constipation, a frequent
intake (if medical condition permits) to a and possible life threatening side effect. monitor hydration effectively themselves increase fluid intake further during warm weather. D. Monitor oral intake. Baseline data will
D. To provide consistency in
E. Encourage 15-30 minutes of exercise
E. To prevent constipation.
(e.g. walking) at least three times a week. If the Individual is not capable, refer to rehabilitation therapist for alternative activities. F. If the Individual becomes constipated
F. It is estimated that up to 60% of
during clozapine treatment, observe stool physician. If the Individual does not have a bowel movement within 48 hours, refer Individual to the physician. G. Continue to encourage fluid intake
and supplemental liquid dietary fiber, e.g., prune juice and/or a fiber enhanced supplement. The Registered Dietician and physician treat additional modifications in fiber on an individual basis. H. If the Individual has a fecal impaction
H. If the Individual has a fecal impaction
immediately for evaluation and intervention(s). I. Educate the Individual for possible side
effects of sedation and/or dizziness. Benign hyperthermia (5% of Individuals) usually occurs early in the treatment and may be as high as 104 degrees. As with any other fever, an infectious process should be ruled out. Tachycardia has been observed in about 25% of Individuals who experience an average increase of 10 - 15 beats per minute. It is dose dependent. J. A towel may be placed on the
J. Hypersalivation is a known side effect
Individual's pillow at night for increased (affecting approximately 31% of Individuals). K. The Individual may cough at night due
K. If the Individual coughs often at night
to hypersalivation. If excessive coughing attention of the physician and documented by the staff in the Individual’s chart. E. Managing Identified Adverse Reactions: A. Maintain the Individual's
A. Seizures increase in likelihood as the
safety.Observe the course of the seizure and record. Hold the medication and report to the psychiatrist. A. Teach the Individual to sit on the edge
A. Orthostatic hypotension can be a side
of the bed several minutes before rising, then to rise slowly to a standing position. B. Have the Individual report any
B. Individuals with pre-existing cardiac
conditions are at highest risk. Individuals receiving benzodiazepines are also at risk. F. Continuity of Care when Individuals are transferred from One Unit to Another: A. The transferring unit will notify the
A. Weekly or bi-weekly blood-draw
sufficient time to allow the receiving unit without a current WBC (no older than seven (7) days). B. The transferring unit will return any
C. The receiving unit will obtain
medication as described in above Section II B. G. Continuity of Care after Discharge from the Hospital: A. If the Individual is going to court or is
A. The Nursing Discharge Summary is an
essential tool to assure that the continuity pertinent aftercare information (e.g. last 3 WBC dates and results).
B. If Individual was recently taken off
B. To prevent an atropine overload, at the
discontinued date of Clozapine is required. To continue to monitor the Individual for side effects till the medication is no longer

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