Case Study- Ms Kay Kruzowski - Drug Combinations - Assessment Answer

December 08, 2018
Author : Ashley Simons

Solution Code: 1AADC

Question: Case Study

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Case Study Assignment

Case Scenario

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)

Assignment Task

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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Solution:

Introduction

Q1 Three risks with the use of Three Different Drug Combinations

Spironolactone and Perindopril may be used in this case but it may have certain other complications, especially for Ms Kruzowski who is 76 years old.  According to Williams (2011), Spironolactone is a drug that regulates the potassium levels in the body ensuring that the level does not get too low.  Perindopril is an ace inhibitor, and its combination with Spironolactone may lead to the severe consequence of Hyperkalemia.  In this condition, the patient administers a very high level of Potassium in the blood content of the patient.  Potassium is essentially required for the myosin contraction and relaxation that causes the proper movement of the muscles in the body.  However, fluctuation of the normal potassium levels in the blood can cause the impairment of the muscular activity of the muscles, including the muscle of the heart.  This impairment in the functioning of the heart muscles of a patient of 76 years of age like Ms Kruzowski may cause the risk of Arrhythmia.  Therefore, this drug combination (Spironolactone and Perindopril), is not being advisable for an elderly patient like Ms Kruzowski.  This condition needs a proper scrutiny and hence a combination of Aspirin and Voltaren Rapid is very appropriate for Ms Kruzowski.

Aspirin, Spironolactone and Perindopril is another drug combination, which may be applicable for this cause.

However, this triple-drug combinational may have minor complications for the patients of older age groups like Ms Kruzowski.  According to Forster & Dezsi (2016), Spironolactone maintains a desirable potassium level in the blood.  This effectively lowers the blood potassium level in the blood of the patients.  It ensures that the potassium levels in the blood do not exceed the permissible limits.  Perindopril, on the other hand, is an ace inhibitor that effectively monitors the sodium, potassium and the blood pressure in the body of the patients.  However, this drug combination of Aspirin, Spironolactone and Perindopril will lead to a serious consequence referred to as the Triple Whammy Effect.  In this condition, the patient experiences a reduction in the blood flow to the glomerulus of the kidney that is associated with the ultrafiltration.  This condition also leads to the reduction in the ultrafiltration ability of the glomerulus.  Aspirin may block the prostaglandin production.  This cumulatively leads to the renal problem.  As Ms Kruzowski is 76 years old, she already has feeble body proportions of good health. This risk is increased manifolds after this drug combination.  Therefore, it is evident that she had been advised the perfect drug of a combination of Aspirin and Voltaren Rapid, according to her previous complications and age.

NSAID and Warfarin can also be a drug of choice.  Nevertheless, a patient of the age of Ms Kruzowski may have complications using this drug of choice.  According to Choi et al. (2010), Warfarin is a drug that is commonly administered for the anticoagulation activity that reduces the chances of blood clots.  It allows the reduction in the clotting ability of the blood in the body of the patients.  Warfarin effectively causes the lowering of the blood clotting ability of the blood.  However, this administration requires the continuous monitoring of the INR blood tests for a productive result of the drug.  According to Kaye, Baluch & Scott (2010), NSAID’s (Non-Steroidal-Anti-Inflammatory Drug) are generally administered to the patients to reduce the pain sensations.  These sensations may include headaches, joint pains, flu, arthritis and other factors that cause pain.  A drug combination of NSAID and Warfarin causes the bleeding in some patients with varied INR results.  Warfarin and NSAID’s increases the INR level of the patients.  These may cause severe bleeding in the patients due to the inability of the blood to clot as induced by Warfarin.  This may serious problems in patients of older age like Ms Kruzowski. Therefore, it is obvious that a combination of Aspirin and Voltaren Rapid the best-suited combination for Ms Kruzowski due to her increased age and her previous complications.

Q2 Strategies of nurses to prevent and manage the above-mentioned risks

Age continues to be a predisposing factor for the treatment of various diseases.  Age is a barrier for the effective administration of the drug or a combination of drugs.  This age difference in adults may have different side effects as compared to the younger individuals.  As Ms Kruzowski is 76 years old with previous other complications, she may be exposed to different side effects of the above-mentioned drug combinations.

Warfarin reduces the clotting ability of the blood.  The INR results serve the license for the administration of Warfarin.  However, an aged patient like Ms Kruzowski being 76 years of age has severe complications about the use of the drug combination of Aspirin and Warfarin.  Aspirin is a NSAID that aims at reducing the pain in the patients.  The nurse or the healthcare worker at the service of MS Kruzowski must have an intense knowledge about the psychological side effects of using this drug combination.  According to Nole et al. (2016, p.125), the nurses need to have a brief knowledge about the INR results and their relationship with the intake of the Warfarin.  If this balance is disturbed the patient have the serious consequence of excessive bleeding.  This bleeding may have other events related to the disease cycle, and its management becomes increasingly critical at the age of 76.  Due to the inability of the blood clot, these bleeding symptoms can assume a bigger consequence as she may be deficient of blood and has to be admitted to the hospital.  Moreover, the anti-inflammatory drug in combination with Warfarin has an addition burden with the loss of understanding the discomforts that Ms Kruzowski may perceive.

As Ms Kruzowski is 76 years old, she may have different side effects for using a drug combination of Spironolactone and Perindopril.  It is evident that this drug combination may lead to an acute phase of Hyperkalemia.  Due to the excessive Potassium in the blood levels of Ms Kruzowski, she may have ineffective muscular contractions and relaxation.  Therefore, this hampers the effective muscular activity of the Heart.  Ms Kruzowski must not be allowed for a vigorous exercise regularly.  She must be intensively monitored to prevent the risk of having stress in the heart muscles.  According to Iliffe et al. (2016, p.69), the nurse must also ensure that Ms Kruzowski must not have any psychological problems with the surroundings that she may be exposed to.  She must not be allowed to have any glance about the unpleasant new as she may have a high tension relating to the news.  This may cause damage to the muscular activity of her heart. Pelone et al. (2015, p.105) state that smiling is a physical cure for the heart diseases; it must be ensured that she abstains from any sad stress from the society.  It should also be managed by the nurse that Ms Kruzowski has peaceful sleeping hours and mental state of rest during the night.  As Ms Kruzowski is 76 years old, she must have the emotional sense of helplessness haunting her psychology.  The nurse must have an education about the treatment procedure to make Ms Kruzowski feel about the availability of help immediately whenever she encounters a need for help.

As Ms Kruzowski is 76 years old, she may have a Triple Whammy effect with the combination of Aspirin, Spironolactone and Perindopril.  Spironolactone monitors the level of Potassium in the blood of the patient.  Perindopril also monitors the potassium and the blood pressure of the patient.  Aspirin serves as an anti-inflammatory drug that relieves the sensation of pain.  These three-drug combinations may cause Triple Whammy Effect on Ms Kruzowski.  This causes a reduction in the renal ultrafiltration.  Aspirin effectively may block the prostaglandin production and cause the severe renal problem to Ms Kruzowski.  The nurse at this moment has a great difficulty in maintaining the proper urination of the patient.   According to Goodman et al. (2016, p.269), at the age of 76, Ms Kruzowski must have the liability to express her comforts and discomforts to the care worker.  This communication is possible if the nurse has a positive sense of interaction and care for Ms Kruzowski.  These interactions may increase with the increase in the individual culture values of the health care provider. Dealing with the renal problems involves the efficient exposure of Ms Kruzowski to consume water more than she actually requires.  This may result in the psychological disturbance in Ms Kruzowski due to her old age.

Patient education needs to be adopted for the patients, however informing Ms Kruzowski about the future complications of this drug combinations will make her abstain from using these drugs because of the old age.  She may develop a negative psychology about her treatment procedure and will not act accordingly.

Q3 Advantages of Regular uptake of Analgesic as compared to Occasional Administration

Aspirin is an Anti-inflammatory drug that effectively reduces the pain sensations in the body.  It has been reported that regular Aspirin use may provide a result that can prevent the onset of colorectal cancer.  Moreover, Devereaux et al. (2014) further demonstrated that the withdrawal of regular dosage of Aspirin a week before surgery might lead to Thrombosis.  However, using aspirin regularly more than the prescribed dosage will have the negative impact on the health.  However, it is also reported that regular aspirin use has no relationship with breast cancer.  Therefore, it is advisable for the patients to have regular Aspirin as per the dose prescribed by the doctor.

Q4 Explaining Warfarin and INR Blood Tests, along with their utility in Ms Kruzowski’s treatment

Warfarin is generally administered to Ms Kruzowski to ensure that the drug is an anticoagulant and does not lead to heart attack.  According to Shi et al. (2015), Warfarin use increases the positive results of the INR test.  A high INR result means that the patients require more time for the blood to clot.  This INR results in patients of elder age must effectively range between 2 and 3, especially in the case when a drug like Warfarin is administered.  Mr Kruzowski had been prescribed to undergo INR blood test once in a week.  This ensures the safety of Ms Kruzowski as the INR results reflect the account of the administration or withdrawal of Warfarin.  Accordingly, the doctor may stop the Warfarin dose whenever the INR results vary.  According to Jackson et al. (2016, p.86), the nurse must have the serious knowledge about the consequences and the overcoming of these situations.  Therefore, this method is highly effective for Ms Kruzowski.

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