case study pharmacology

Running head: NURSING CONSIDERATIONS IN A CASE STUDY 1

Nursing Care and Considerations in a Case Study

Maggie M. Fabry

California State University Stanislaus

NURSING CONSIDERATIONS IN A CASE STUDY 2

Nursing Care and Considerations in Pharmacology

Mr. Brown is a 65 year old patient who has a known history of Diabetes, hypertension,

and Alzheimer’s disease. This patient recently had a fall and a fracture of his left hip and is now

being admitted for surgery. Findings of significance made during his assessment include crackles

in the bases of his lungs, swelling in his lower extremities bilaterally, an elevated potassium level

of 5.5 and an elevated creatinine level of 1.5. In addition, Mr. Brown is alert and oriented times

two, has not had a bowel movement for three days and reports eight out of ten pain in his left hip.

His current vital signs are 37.6-88-24-165/96. During his stay, an assessment and evaluation of

his home medications, an investigation into the reason for his fall, considerations for a suitable

pain medication and interventions during post operative care will all prove to be important

nursing actions involved in the proper care of this patient.

The medications that Mr. Brown takes at home convey information about his health

problems. Firstly, Mr. Brown takes Spironolactone which is a potassium-sparing diuretic used

primarily for hypertension and edema. It acts through inhibiting the actions of aldosterone which

results in the increased secretion of sodium and the retention of potassium. Through this action,

Spironolactone creates osmotic pressure in the nephron, and passive reabsorption of water is

prevented. As a result of less water being present in the blood, blood volume and cardiac output

decline and blood pressure lowers. As a result of less water traveling into body tissues, edema is

reduced. Mr. Brown is receiving this medication because he has a known history of

hypertension and because he has pulmonary edema as suggested by the crackles present in the

bases of his lungs. Mr. Brown’s next home medication is Lisinopril which is a long-acting

angiotensin-converting-enzyme (ACE) inhibitor. Through inhibiting ACE, Lisinopril both

vasodilates and reduces blood volume. Lisinopril causes vasodilation through two actions. First,


through inhibiting the angiotensin-converting enzyme, it prevents the conversion of angiotensin l

to angiotension ll which is a potent vasoconstrictor. Secondly, it inhibits kinase ll which

increases levels of bradykinin, a peptide that causes vasodilation. Blood volume is reduced

through the reduction of aldosterone which occurs secondary to the inhibition of angiotensin ll.

Vasodilation reduces peripheral resistance and lower blood volume reduces cardiac output,

which are the two primary determinants of blood pressure. Mr. Brown is taking Lisinopril at

home to lower his blood pressure because he has hypertension. Mr. Brown’s next home

medication is Metformin which is a part of the Biguanide family of oral agents used to treat type

2 diabetes. Type 2 diabetes is a disease in which the target tissues of insulin are resistant to its

effects, meaning that glucose does not get transported to these tissues, but rather accumulates in

the blood. Metformin improves tolerance to glucose and lowers blood glucose levels in the body

through three mechanisms of action. Firstly, Metformin inhibits the formation of glucose in the

liver. Secondly, it slightly lessens the absorption of glucose in the gut. Thirdly, it makes insulin

receptors more sensitive in fat and skeletal muscle and, as a result, increases the uptake of

glucose. The fact that the pt is taking a single oral hypotensive agent tells me that he has

recently been diagnosed with or has well controlled type 2 diabetes. Aricept is another of the

patient’s home medications. Aricept is a Cholinesterase inhibitor used in the treatment of

Alzheimer’s disease (AD). AD is a chronic, degenerative, progressive disease that consists of

memory loss, impaired thinking and neuropsychiatric symptoms. Although the cause is

unknown, what is known is that in pts with AD, levels of acetylcholine (ACh) are significantly

below normal. Aricept works to prevent the breakdown of ACh by acetylcholinesterase (AChE)

and, as a result, enhances the availability of ACh at cholinergic synapses. Through this action,

central cholinergic neurons that have not yet been destroyed by Alzheimer’s disease (AD) will


have enhanced transmission. Aricept is the only cholinesterase inhibitor approved for AD

patients with severe symptoms. For this reason, it is reasonable to conclude that Mr. Brown has

AD and is displaying severe symptoms of the disease. Mr. Brown’s last home medication is

Prilosec which is a proton pump inhibitor (PPI) used to treat peptic ulcer disease (PUD). PUD

refers to a variety of disorders in the upper gastrointestinal tract that are distinguished by their

degree of erosion of the gut wall. Ulceration develops when there is an imbalance between

aggressive and defensive mucosal factors. A major aggressive factor is gastric acid. Once

activated in the parietal cells of the gut, Prilosec causes irreversible inhibition of H+,K+-ATPase

which is the enzyme that produces gastric acid (Lehne 2010). It is especially important that Mr.

Brown does not have an increased production of gastric acid in his stomach because he is taking

Spironolactone, which can cause gastric bleeding, ulceration and gastritis. All of these adverse

effects will have an increased risk of occurrence in the presence of excessive gastric acid

(Skidmore-Roth 2013).

Through investigating the patient’s assessment findings and his health history, judgments

can be made about the effectiveness of the medications he is taking at home. Due to the presence

of crackles in the base of his lungs and his severely elevated blood pressure, it is apparent that

Spironolactone is not effective in reducing blood pressure or edema for Mr. Brown. An

important side effect of Spironolactone is hyperglycemia. The patient’s dose of Metformin may

need to be increased accordingly (Skidmore-Roth 2013). Lisinopril is similarly ineffective. As

evidenced by his blood pressure of 165/96 during assessment, Lisinopril is failing to control the

patient’s blood pressure. Another area of concern is that both Spironolactone and Lisinopril

cause hyperkalemia (Lehne 2010). The patient’s current serum potassium level is elevated and

at 5.5, which confirms that these two medications should not be used together. One other


important side effect of ACE inhibitors when looking at this patient’s results is the fact that they

can cause an elevated creatinine level (Pagana 2010). Metformin, on the other hand, is being

effective in lowering the patient’s blood glucose levels. The patient’s Hgb A1C is 7.0 which is

an acceptable value. It is important to mention that because Metformin does not stimulate the

release of insulin from the pancreas, it cannot cause hypoglycemia and is a good choice for

patients like Mr. Brown who skips meals (Lehne 2010). One interaction of note is the potential

for hypoglycemia when Lisinopril and a glucose lowering agent such as Metformin are used

together (Skidmore-Roth 2013). Aricept is also ineffective for this patient. This is evident by

the fact that the patient is alert and oriented times two. The patient’s recent fall may also be

indicative of increased confusion and disorientation associated with AD. In general,

Cholinesterase inhibitors only create modest and short lasting results for patients with AD

(Lehne 2010). Prilosec does appear to be effective in this patient. The patient’s complete blood

count was normal and did not display symptoms of gastrointestinal bleeding such as an elevated

red blood cell count, hemoglobin or hematocrit level (Pagana 2010). In addition, the patient is

not complaining of any stomach pain which can be an indication of erosion and ulceration

(Lehne 2010).

When looking at the patient’s history and assessment findings, reasonable deductions as

to the reason for Mr. Brown’s fall can be made. The first plausible reason for Mr. Brown’s fall is

the fact that he is taking Lisinopril which can cause orthostatic hypotension (Lehne 2010).

Orthostatic hypotension is a sudden decrease in blood pressure that results when rising to an

upright position. This sudden drop can result in lightheadedness and dizziness and in severe

cases, can cause fainting (Klingman 2013). A second reason for the fall could be the patient’s

high potassium level of 5.5 which can be the result of his use of both Spironolactone and


Lisinopril. Characteristics of hyperkalemia that can contribute to falls are numbness or tingling

of the feet, weakness of the legs and confusion. A third and final reason for the fall could be the

patient’s AD. AD can cause memory loss and confusion, impaired judgment and disorientation

and feelings of being lost in surroundings that are familiar to the patient (Lehne 2010). All of

these changes caused by AD can increase the chances for falls.

A priority consideration for any patient with a fractured bone is pain control. In the case

of Mr. Brown, Morphine would be the most probable drug prescribed for his pain. Morphine is

an opioid analgesic used to relieve moderate to severe pain that is thought to act through binding

with opioid receptors in the CNS and altering both the perception of and emotional response to

pain (Skidmore-Roth 2013). Morphine reduces pain and anxiety, causes drowsiness and mental

clouding, and can induce a sense of well-being (Lehne 2010). Although Morphine has

potentially dangerous side effects such as seizures, bradycardia, cardiac arrest, shock,

thrombocytopenia, apnea, and respiratory depression, it has many beneficial effects for this

patient that outweigh the potential costs (Skidmore-Roth 2013). Another concern is that giving

Morphine can further delay a bowel movement for this patient who has not had one in three days

because it causes constipation. However, even if a moderate opioid agonist such a hydrocodone

was used, constipation would still be an adverse effect. A clear benefit of using Morphine with

this patient is that it can assist with sedation and anxiety reduction preoperatively. Morphine’s

side effect of respiratory depression can also serve as a benefit in this patient because his

respiratory rate is at an elevated 24 breaths per minute. Morphine can also cause hypotension

through its action of dulling the baroreceptor reflex. This effect can be positive for this patient

given his high blood pressure (Lehne 2010). Finally, it is a plus that Morphine can be given

intravenously (IV) because it results in rapid relief of pain for the patient. In contrast to oral


analgesics which can take 30 minutes to display initial results, IV Morphine reaches its peak

effectiveness in 20 minutes (Skidmore-Roth 2013).

Orders for Promethazine and routine bowel care in this post-operative patient offer many

benefits, but also require numerous nursing considerations. Promethazine is a first-generation

H1 Antagonist and antiemetic that has been prescribed post-operatively to reduce anesthetic

related nausea. The obvious benefit of taking this medication is a relief of nausea which will

promote eating and mobility for this patient. Another benefit is that this drug causes sedation

and can therefore combat insomnia that is often present in patients with AD (Lehne 2010).

Important things to watch for when giving this drug are signs and symptoms of neuroleptic

malignant syndrome such as confusion, autonomic instability, muscle rigidity, and fever. It is

also important to monitor hydration level, mental status and for improvements in nausea

(Skidmore-Roth 2013). Routine bowel care will also benefit this patient through promoting

peristalsis and preventing constipation which can be both painful and potentially dangerous.

Routine bowel care includes interventions that increase peristalsis such as activity and mobility,

an increase in fiber intake, adequate hydration and the use of laxatives and stool softeners.

During the assessment of the abdomen, the nurse will be looking for signs of impaction such as a

hard distended stomach, hypoactive or absent bowel sounds and pain upon palpation. The nurse

will also be looking for adverse reactions of laxatives such as severe cramping, diarrhea and

nausea. Finally, the nurse must check for patient understanding after performing teaching on

proper fiber intake (eating three to five handfuls of fruits and veggies per day) and on proper

hydration (drinking two to three liters of water every day) (Lehne 2010).

Each patient a nurse cares for is unique and requires individualized care. In the case of

Mr. Brown, priority interventions include pain reduction, early ambulation and promotion of


gastrointestinal motility. An important lesson to be learned through looking at Mr. Brown’s case

is the importance of initial assessments and of examining home medications for effectiveness

and interactions. Furthermore, Mr. Brown’s case demonstrated the importance of using critical

thinking and the nursing process in medication administration and in each and every other

nursing intervention.


References

Klingman, L. (2013). Bowel Elimination. In P. A. Potter, A. G. Perry, P. A. Stockert, & A. M.

Hall (Eds.), Fundamentals of nursing (pp. 1087-1126). St. Louis, Missouri: Elsevier &

Mosby.

Lehne, R. A. (2010). Pharmacology for nursing care. St. Louis, Missouri: Saunders & Elsevier.

Pagana, K. D. & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests. St.

Louis, Missouri: Mosby & Elsevier.

Skidmore-Roth, L. (Ed.). (2013). Mosby’s 2013 nursing drug reference. St. Louis, Missouri:

Mosby & Elsevier.

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