Q. 1 Assess Mrs Daps’ medication chart. Discuss three (3) significant risks involved with Mrs Dap’ home and/or inpatient use of medicines.
Based on Mrs Dap’s medication chart, it shows that the patient is being administered with regular, variable dose and PRN medications. The patient requires several medications that are specific to her condition. However, the number of medications scheduled for Mrs Dap could potentially cause a medication interaction, even though each targets specific condition. For example, the patient is being administered with 10mg of Felodipine daily, which is a CCB type of medication. However, calcium channel blockers tend to create an interaction interferes with effectiveness and in some cases creates side effects when taken with antibiotics, pain relievers and herbal-based supplements like garlic (Beauchamp, n.d.). According to the patient’s chart, the doctors allowed the patient to take her preferred garlic supplement and in fact also taking Paracetamol for pain variations of antibiotic medications. In addition, there was also a request for 50mg. of Voltaren to be taken when required. The patient also prefers Voltaren as her pain medication. However, the patient is already taking Paracetamol for pain every six hours. Therefore, there is no need to take Voltaren or could have just prescribed either one of the pain medications. Another noticeable potential interaction in the chart medication is that the patient is also administered with 4mg of Warfarin with the brand name Coumadin, which is an anti-coagulant. It is also highly recommended to avoid taking Warfarin when taking pain medications, antibiotics and supplements that decreases clotting such as garlic. On the other hand, the use of 100mg hydrocortisone appears to be appropriate to address the Mrs Dap’s respiratory problems particularly the breathing difficulties. Side effects or interactions are possible with other drugs, but does not always occur. However, taking the medication along with herbal supplements would render hydrocortisone ineffective. Furthermore, several risks may occur as a result of interactions in the medications based on the patient’s chart.
Risk for Bleeding
Risk for Renal Function Failure
Triple whammy is the term used to describe renal impairment when ACE-I (Angiotensin converting enzyme inhibitor), NSAID’s (Non-steroid anti-inflammatory drugs) and diuretic drugs are used in a combination (Loboz & Shenfield 2005). Mrs Dap has been written up for perindopril and amiloride as regular medication and Voltaren as required. Normally blood flow to the renal system is controlled by prostaglandin synthesis (Lemone & Burke 2011). The use of Voltaren causes prostaglandin synthesis inhibition resulting in a reduction of blood flow to glomerulus as a result of vasoconstriction of afferent arterioles. This reduction of blood flow to the glomerus is further enhanced by the use of perindopril in conjunction with Voltaren. Perindopril causes vasodilation to the efferent arterioles resulting in a reduction to glomerulus filtration rate. With decreased blood flow to the glomerulus, the use of amiloride with both the Volataren and perindopril will increase fluid volume in the glomerulus filtration. This increase to fluid volume can put significant pressure on renal function as fluid is unable to get filtered and excreted fast enough and this can potentially lead to acute renal failure.
Polypharmacy
The use of multiple drugs that have no real indication, have increased interactions, contraindications and increased adverse effects are known as polypharmacy (Bullock& Manias 2011). Mrs Dap is on a number of medications that have high interaction and adverse effect. An example of drug interaction is the use of garlic capsule with warfarin, in this case it is inappropriate for Mrs Dap to take garlic capsules as it prolongs prothrombin time due to its antiplatelet properties and thus impacting therapeutic outcome (Bhandari 2012). Another example of drug interaction and heightened adverse effects is the use of Perindopril, Felodipine and Amiloride/ hydrochlorothiazide together which all cause hypotensive affect. The increased use of multiple medications can put Mrs Dap at a risk for experiencing increased adverse effects, falls and acute renal failure (Kojima et al 2012). These risks increase with ageing as renal and hepatic function declines and drug accumulation increases and may cause impairment in these end organs (Chang et al., 2012).
Q.2 Describe the strategies a nurse may take to prevent/manage the specific risks you have identified in Question 1. Your answer should focus on Mrs. Daps’ needs rather than a discussion of these medicines in general terms.
Risk for Bleeding
Close monitoring of IRN blood test are vital in reducing risk for bleeding for Mrs Dap (Australian Prescriber 2002). Nurses must ensure that IRN levels are within therapeutic range in order for warfarin to be administered. In this situation the nurse would immediately inform the prescribing doctor about Mrs Dap’s IRN test results, as they happen to be above the target range. In order to prevent further bleeding nurses should ensure that Mrs Dap is free from bruises at all time as she has a history of falls. Minimising the number of objects that Mrs Dap comes in contact with and making sure that the environment is free from clutter to reduce her chances of having a fall can achieve this. Regular monitoring of signs of bleeding, bleeding gum and bruising should also be done (Burke & Lemone 2004, pp.480-81).
Risk for impaired renal function
The pressure that is put on the renal function from the combination of ACE-I, NSAID and diuretic can potentially impair renal function. Careful monitoring of blood urea nitrogen (BUN), serum creatnine, electrolyte, pH levels and complete blood count is needed, as they are good indicators of normal renal function (Burke & Lemone 2004, pp. 699-700). Any significant changes should be reported to the prescriber. A decline in glomerulus filtration rate can increase BUN and serum creatinine levels, which indicate impairment in renal function. Mrs Dap’s Urea and creatinine levels are slightly high indicating that she’s either hypovolemic or has renal impairment. The nurse should immediately inform the prescribing doctor about Mrs Dap’s laboratory tests and the medication she has been prescribed. Careful monitoring of respiratory status especially lungs sounds every 4 to 8 hours and Electrocardiography assessment is also vital in the care of Mrs Dap, as reduced glomerulus filtration rate can lead to fluid overload and cause fluid to shift to the lungs and heart and cause complication in these areas (cardiosmart 2012). In order to prevent the triple whammy effect, other alternative such as use of codeine or non-pharmacological treatments should be considered as pain reliever instead of the use of Voltaren.
Polypharmacy
Close monitoring of drug interaction, dosage and adverse events is necessary in the care of Mrs Dap. Increased supervision of Mrs Dap medication and overall status is necessary in order detect any defects and early detection of undesirable effect. Nurses should examine laboratory test such as serum creatnine, urea and electrolyte and complete blood count in order to detect potential complications with renal and hepatic function, as the use of ACEI, diuretic and NSAID can impact renal function (Kim et al 2009). The nurse should also monitor signs and symptoms for insomnia, tachycardia, hypotension, confusion, tremor and nausea as this can indicate toxicity (Burke & Lemone 2004) and report any significant changes physiological status. The nurse can suggest a preview of Mrs Daps medication so that appropriate medication can be prescribed and inappropriate medication can be discontinued.
Q. 3 the doctor has ordered regular paracetamol to be given for back and rib pain for this patient. Explain the benefits of regular analgesic dosing rather than administration when pain is noticeable. Your answer should include relevant pharmacokinetic concepts.
In order to maximise control over her pain, Mrs Dap needs to be given paracetamol on regular basis rather than when pain becomes visible. When given in an oral form paracetamol is metabolised by the liver and excreted by the kidneys (AMA 2012). This metabolism reduces its bioavailability and therefore needs to be given on a regular basis to have a therapeutic effect. The use of regular paracetamol creates a steady state concentration level. This means that equilibrium has reached between drug administration and drug elimination. The benefits of a steady state concentration is that concentration of paracetamol in the circulatory system is maintain over time and therefore drug availability to tissue is increased resulting in decreased pain sensation (Bullock & Manias, E 2011). As pose to as required administration, which has a quick effect, and last in the circulatory system for a short period. Steady state concentration is usually achieved after 4 to 5 half-life and therefore it is important not to delay administration of paracetamol as this can affect its concentration. PRN administration of paracetamol is not beneficial to Mrs Dap, as it is short acting and would not maintain pain control overtime. Regular administration of paracetamol means that Mrs Dap pain is controlled before it appears and it also means that she able to perform appropriate activities such as deep breathing and coughing without having to feel pain.
Q. 4 Mrs Daps is prescribed warfarin. INR blood tests are ordered to guide the dosage of warfarin. Explain these tests and their purpose in her treatment plan. Your answer should briefly include the nurse’s role with respect to these tests.
INR blood test is a standard coagulation test, which looks at an individual’s prothrombin time (Bullock & Manias 2011). This test is used to determine the clotting propensity of blood as guidance in administering warfarin. INR blood tests are usually taken from patients who are commencing on anticoagulant therapy such as warfarin. Prescribing doctors ensures that INR blood test are taken every morning so that adjustment to warfarin dosage is made in treating patients with thrombotic disorders such as deep vein thrombosis. In regards to Mrs Dap situation, the nurse must ensure that her INR blood test is taken and the results along with warfarin order for that day are returned by the end of the day. The nurse cannot administer warfarin without obtaining the INR blood tests first (Bullock, Manias & Galbraith 2007). Therefore, it is important for the nurses to confirm that INR blood test; target range and dosage of the warfarin are correctly charted on the medication chart.
An individual’s normal prothrombin time is about 12-15 seconds and their INR test without the use of anticoagulant drugs is around 1.0(Bullock & Manias 2011). However, results can be heightened in individuals whom are receiving warfarin therapy, as their clotting time can be lengthened. Prescribers usually aim for an INR of 2.0-4.0 for individuals who are commencing on warfarin depending on the individual’s situation. If INR blood test exceed or drop below the set range that has been prescribed to them, individual can be at a high risk for bleeding or developing clots. In these situations nurse are strongly advised to notify prescriber before administrating warfarin.
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