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On 1st September, Ms Kay Kruzowski, aged 76 years, was admitted to the medical unit having been transferred to the unit from the emergency department where she was admitted with suspected pneumonia and inability to cope at home on her own.
For 10 days prior to admission, Ms Kruzowski had been taking an oral antibiotic (Augmentin Forte) for a chest infection. Additionally, two weeks ago, she sustained fractures of two ribs after tripping over her cat.
She has a past history of hypertension, back pain (exacerbated by her recent fall), and a deep vein thrombosis in her right leg (2 years ago).
As a result of her chest infection, Ms Kruzowski has been commenced on intravenous ceftriaxone and erythromycin. She states that in the last week she has commenced taking ‘garlic capsules’ [herbal medicine] that the lady in the chemist said is good for her current chest complaint. She “really likes vitamins and herbal medicines as they are all natural, being safer than the chemicals the doctor gives you”.
Ms Kruzowski insists that the resident doctor prescribes her usual ‘garlic capsules’ as well as the Voltaren she occasionally takes when she gets a sore back. Her usual daily medicines are as charted on the medication chart.
Ms Kruzowski’s observations are presently:
Temperature: 39.1 0C (tympanic) Pulse: 112 bpm regular Respiration 26 bpm Blood pressure: 102/62 mmHg SpO2: 95% on RA Height: 165 cm Weight: 61.4 kg
Her blood test results are all within normal limits except for the following:
Urea: 9.0 mmol/L (normal range 2.0- 8.5 mmol/L) Creatinine: 0.19 mmol/L (normal range 0.05 – 0.09 mmol/L for females) INR: 3.2 (6 days ago: Range set for this patient 2.0 – 3.0)
Q1. Assess Ms Kruzowski’s medication chart. Identify and explain three significant risks that may be associated with the use of the medicines (home or inpatient use) for Ms Kruzowski.
Areas to consider when addressing this question are: What is the mechanism of each risk? Why is the risk significant in this case? Are there any factors/effects that contribute to the risk? Relate your answer specifically to Ms Kruzowski.
Q2. Describe the strategies a nurse may take to prevent/manage the specific risks you have identified in Question 1. Your answer should focus on Ms Kruzowski’s needs rather than a discussion on the actual medicines.
Areas to consider when addressing this question are:
Pharmacological strategies (specific to the particular drug) Specific nursing assessment Specific patient education (if applicable) Relate your answer specifically to Ms Kruzowski.
Q3. The doctor has ordered regular paracetamol to be given for Ms Kruzowski’s back and rib pain. Briefly explain the benefits of regular analgesic dosing rather than administration when pain is noticeable. Your answer should include relevant pharmacologic concepts.
Q4. Ms Kruzowski is prescribed warfarin and INR blood tests are routinely undertaken with this medication. Briefly explain these tests and their purpose in her treatment plan.
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Ms Kruzowski is a 76 years old patient that was admitted to the hospital after being suspected of having pneumonia as well as the lack of ability to cope at home on her own. After reviewing Ms Kruzowski’s medical chat, it is evident that she has been prescribed with a diverse range of medicinal drugs which include Warfarin, garlic capsules, Aspirin, Ceftriaxone, Perindopril, Felodopine, and Voltaren. The use of these medicines can be associated with a number of significant risks.
The first major risk that Ms Kruzowski faces in relation to her medication is the risk of easily bleeding. By the combined consumption of Warfarin, garlic capsules, Ceftriaxone, as well as Aspirin is one of the multiple factors that put Ms Kruzowski at risk of easy bleeding. The use of Aged Garlic Extracts (AGE) prevents the aggregation of platelets by heightening the number of cyclic nucleotides and preventing fibrinogen binding and platelet shape change (Rahman, Lowe, & Smith, 2014). Considering that platelet aggregation is the clumping and sticking together of platelets to form blood clots that stop bleeding, the continued use of AGE by Ms Kruzowski puts her at risk of easy bleeding. Ms Kruzowski is also under Warfarin (Rahman, Lowe, & Smith, 2014). The liver synthesizes proteins that are responsible for forming clots in the blood and requires vitamin to do so. Warfarin is referred to as vitamin K inhibitor since it diminishes the liver’s ability to use vitamin K to synthesize the proteins required to form blood clots. The continued use of Warfarin, therefore, places Ms Kruzowski at risk of easy bleeding. Moreover, the simultaneous use of vitamin K inhibitor Warfarin with Ceftriaxone may heighten the risk of bleeding. In addition to the risk of bleeding as a result of impaired synthesis of vitamin K due to treatment with Warfarin, Ceftriaxone may increase the risk of easy bleeding due to its effect on clotting factor monitor INR.
Ms Kruzowski is also at risk of tachycardia. This is a condition where the patient has a faster than normal heart rate when at rest. Ms Kruzowski has been taking Perindopril, which is an angiotensin-converting-enzyme (ACE) inhibitor, and Felodopine, which is a Calcium channel blocker, to lower her blood pressure. Both of these medications are antihypertensive medicines (Neil, Skolnik, & Beck, 2010). ACE inhibitors and Calcium channel blockers are used as medication to lower blood pressure. According to Ms Kruzowski’s results after a physical examination, she is having tachycardia (112bpm) and a relatively low blood pressure (102/62mmHg). Having both tachycardia and not so high blood pressure might be as a result of Ms Kruzowski simultaneously using two antihypertensive medicines (Neil, Skolnik, & Beck, 2010).
The third risk that Ms Kruzowski is facing in relation to her medication is impaired renal function. This risk is shown by the patient’s high Creatinine level (0.19 mmol/L), twice the value of upper limit of normal range (0.09 mmol/L). According to her medication chart, the patient has been prescribed with Voltaren. Voltaren is a Diclofenac, Non-steroidal anti-inflammatory drug (NSAIDs). NSAIDs are a class of medication that are used for anti-inflammatory as well as analgesic benefits (Ejaz, Bhojani, & Joshi, 2009). A large number of NSAIDs have been known to have renal toxicity. In addition, impaired renal function can potentially heighten Diclofenac’s renal toxicity. Moreover, the use of NSAIDs for patients using ACE inhibitors can increase chances of renal impairment (Ejaz, Bhojani, & Joshi, 2009). Therefore, in the case of Ms Kruzowski, she faces a major risk of further renal damage since she regularly takes Perindopril, which is an ACE inhibitor, and Voltaren.
Considering the risks that Ms Kruzowski faces due to her medication, it is extremely important for a nurse to come up with a strategy prevent of manage these risks while simultaneously attending to the medical needs of the patient simultaneously. Since the patient is admitted due to suspected pneumonia as a result of her continued chest pains, she must continue her medication with Ceftriaxone as this medicine is used to prevent or treat infection that has been proven or strongly suspected to be caused by bacteria. Taking both Ceftriaxone and Warfarin simultaneously has been found to increase the risk of bleeding. However, since the patient has to continue using Ceftriaxone medicine due to her continued chest pains, the nurse should decrease her dosage of Warfarin (Rahman, Lowe, & Smith, 2014). Nevertheless, low Warfarin levels in the body might lead to clotting of the blood since high levels of vitamin K will face less inhibition. To avoid easy bleeding or blood clotting there must be a balance between vitamin K and Warfarin. Due the fact that Ms Kruzowski really likes taking vitamins, the nurse should give her advice on what vitamins to take in her nutrition so as to avoid high levels of vitamin K. This will allow the nurse to reduce her dosage of Warfarin and attain balance.
Ms Kruzowski has a history of hypertension and as a result she is using Perindopril, an ACE inhibitor, and Felodopine, a Calcium channel blocker to reduce high blood pressure. Since the patient has a history of hypertension, the nurse should understand that she must take medication for the purpose of reducing her blood pressure (Neil, Skolnik, & Beck, 2010). The simultaneous use of two antihypertensive medicines can cause tachycardia and lead to not so high blood pressure. Therefore, the nurse’s strategy should entail a better suited option on which to use between the two drugs to control Ms Kruzowski’s blood pressure. The better choice for the patient would be for the nurse to prescribe only Perindopril. This is because ACE inhibitors dilate the blood vessels to improve the amount of blood the heart pumps and lowers blood pressure as well as increase the flow of blood which helps in decreasing the amount of work the heart does. On the other hand, the nurse should discontinue Ms Kruzowski from using Felopodine since it is a Dihydropyridine Calcium channel blocker that despite helping to reduce blood pressure, its side effects include tachycardia.
Ms Kruzowski also uses Voltaren, an NSAID, due to her occasional sore back. Since she also takes ACE inhibitor Perindopril to reduce her blood pressure, she faces risk of further renal damage due to simultaneous use of these drugs. The nurse’s strategy involves Ms Kruzowski discontinuing the use of a Calcium channel blocker, to rely only on Perindopril to manage her hypertension. Since the use of Voltaren is not compatible with the use of Perindopril, and also since many NSAIDs have been found to have renal toxicity, the nurse should advice the patient to discontinue the use of Voltaren and rely on garlic capsules to treat her occasionally sore back.
Regular analgesic dossing will give Ms Kruzowski the ability to manage her own pain rather than waiting until her pain is noticeable. In the process of planning and evaluating analgesia, assessment of pain is fundamental (Owen, Plummer, & Armstrong, 2012). The patient should be informed of the significance of regular analgesia, as well as adhering with this advice, since this will allow attainment and maintenance of the therapeutic array of drugs used. With regular analgesic, the patient is educated on the significance of pain management and how recovery relates to adherence (Owen, Plummer, & Armstrong, 2012). Moreover, maintaining a working knowledge on frequently used analgesics contributes to efficiency in practice. Another benefit of regular analgesic dosing is that it empowers patients to develop some degree of control over their pain as it will assist them in alleviating anxiety which will in turn diminish the pain experience. Regular analgesic dosing is immediate as it is effective since patients do not have to wait to have the medication administered (Owen, Plummer, & Armstrong, 2012).
The International Normalised Ratio is the blood test carried out to monitor the effects of warfarin in the body. It is a blood test that monitors how long it takes blood to clot. A normal INR result needs to stay within a particular range ( INR Monitoring: Patient Self-Monitoring, 2010). For people taking warfarin, the target INR should be between 2 to 3. If a person’s INR is too high, their risk of bleeding increases while when INR is low, chances for the individual’s blood to form a blood clot are high ( INR Monitoring: Patient Self-Monitoring, 2010). The target INR assists physicians to adjust a patient’s warfarin dose. This can differ from individual to individual and from time to time. Once a patient’s warfarin dose that achieves their target INR has been stabilized, they will not need to be tested so often but just once in a month. However, more tests might be required from time to time if the patient changes her diet or medicine as their interaction with warfarin may alter the effects of warfarin in the body ( INR Monitoring: Patient Self-Monitoring, 2010).
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