Nursing

Pharmacology Reasoning

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Neurologic Changes Introduction In this unfolding case study that simulates the complexities of clinical practice, you will assume the role of a nurse in the emergency department. You will use a holistic approach to provide safe care by making correct clinical judgments for a patient with neurologic changes resulting from medications or new problems. You will need to apply essential knowledge of pharmacology to notice and interpret the most crucial assessment findings and lab values to properly establish care priorities and recognize a declining neurologic status before it needlessly progresses.

Preparation for Care Activity

Review the home medications of this patient. Prepare for patient care by completing the table below. Medication Indications Mechanism of action

Expected Side

Effects Assessments/

Responsibilities Aripiprazole 10 mg PO daily

Safe dose range: Therapeutic Class: Pharmacologic Class:

Medication Indications Mechanism of action

Expected Side Effects

Assessments/ Responsibilities

Alprazolam 0.5 mg PO BID

Safe dose range: Therapeutic Class: Pharmacologic class:

Pharmacology Reasoning

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Medication Indications Mechanism of action

Expected Side Effects

Assessments/ Responsibilities

Hydrocodone- acetaminophen 5-325 mg tablet one tab every 4 hours PO PRN- pain

Safe dose range:

Therapeutic Class: Pharm Class

Medication Indications Mechanism of action

Expected Side Effects

Assessments/ Responsibilities

Divalproex 500 mg XR 2 tabs PO BID

Safe dose range: Therapeutic Class:

Pharmacology Reasoning

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1. Which findings are most important and must be recognized as clinically significant by the nurse? Most Important Findings Clinical Significance

2. Review the medical history and home medications of this patient. Which medication treats what condition? Draw a

line to identify each clinical relationship. Medical History Home Meds Pharm. Classification

• Anxiety • Bipolar Depression • Schizoaffective disorder

• Aripiprazole 10 mg PO daily • Divalproex 500 mg XR 2 tabs PO

BID • Alprazolam 0.5 mg PO BID

3. Based on this patient's current medications, does the nurse need to address the clinical concern of polypharmacy with

the provider? Polypharmacy Rationale

4. Based on this patient's home medication list, are there any concerning medication interactions that the nurse needs to

communicate to the provider? Medication Interactions Rationale

Patient Care Begins Interpretation: Clinical Significance:

Recognizing a potential problem, you collect a full set of vital signs and complete a nursing assessment:

Pharmacology Reasoning

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5. Which vital sign findings are most important and noticed by the nurse as clinically significant? Most Important Data Clinical Significance

As you complete the head-to-toe assessment, you notice these findings:

6. What assessment data needs to be noticed as most important? Interpret its clinical significance and determine how the

nurse should immediately respond. Most Important Data Clinical Significance Nurse Response

7. What assessment data needs to be noticed as most important? Interpret its clinical significance and determine how the

nurse should immediately respond. Most Important Data Clinical Significance Nurse Response

8. What assessment data needs to be noticed as most important? Interpret its clinical significance. Most Important Data Clinical Significance

The following diagnostic test results just posted in the

electronic health record:

Metabolic Panel Na K Cl CO2 AG Gluc Ca BUN Creat GFR

Pharmacology Reasoning

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Hematology: Complete Blood Count (CBC)

WBC HGB PLTS % Neuts % Lymphs % Monos % Eosin Bands

Misc. Salicylates Acetaminophen Urine Drug

Screen Lipase Lactate (Ven) Hgb A1C

9. Identify which diagnostic findings relate to the home medications or meds that have been recently administered. Place

an "x" for each finding to determine if the results are expected, improved, or worsened. Diagnostic Result Expected Improved Worsened

WBC Neutrophils Hemoglobin Creatinine + for benzo/hydrocodone Acetaminophen 10. After interpreting diagnostic data, what is the priority problem and pathophysiology? Priority Problem Pathophysiology in Own Words

11. Identify the rationale for each provider order and its expected outcome. Provider Orders Rationale Expected Outcome Establish peripheral IV 0.9% NS 1000 mL IV bolus Naloxone 0.04 mg IV. May repeat every 2-3 minutes until consistently awake (Use 0.4 mg ampule of 1 mL and add 9 mL of 0.9% NS in 10 mL syringe for dose of 0.04 mg/1 mL)

Pharmacology Reasoning

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12. What findings will be present if the pharmacologic therapy is effective? When would those findings be evident? Medication Expected Assessment Findings How Long Before

Evident? Rationale

0.9% NS 1000 mL IV bolus

Naloxone 0.4 mg IV. May repeat every 2-3 minutes until consistently awake

13. For the new order of naloxone, apply your knowledge to complete the table below. Medication Indications Mechanism of action Expected Side

Effects Assessments/

Responsibilities Naloxone

Safe dose range:

Therapeutic Class:

Pharm class:

Pharmacology Reasoning

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Dosage Calculation: Naloxone 0.04 mg IV push Medication

Time

frame to Administer

Show Work Volume to Administer

14. After interpreting clinical data collected, identify the current nursing priority and which action(s) the nurse should take. List appropriate interventions, rationale, and expected outcome

Nursing Priority

Priority Intervention(s) Rationale Expected Outcome

Pharmacology Reasoning

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Evaluation 15. The nurse collects the following assessment data below. For each finding, place an "x" to determine if the patient's

condition has improved, has not changed, or has declined. Assessment Data Improved No Change Declined T: 98.4 F/36.9 C (oral) P: 72 (regular) R: 18 (regular) BP: 110/65 MAP: 80 O2 sat: 96% room air 5/10 sharp ache in the left thigh Pupils 3 mm/brisk reactive to light Awake and follows verbal commands 16. Has the patient's overall status improved, declined, or remained unchanged? If the patient has not improved, what

pharmacologic changes could be recommended by the nurse? Current Status Pharmacologic Recommendations (if applicable) Rationale

Documentation Write a concise nurse's note using your program's preferred format to document what was most important in the medical record.

Five minutes after receiving a total of 0.16 mg naloxone IV, the patient is consistently awake and able to follow verbal commands. The nurse collects the following clinical data:

Pharmacology Reasoning

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Nurse Reflection To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by answering the reflection questions below. Reflection Question Nurse Reflection As you worked through this simulation, how did it make you feel?

What did you already know and do well on this simulation?

What areas do you need to develop/improve?

What did you learn? How will you apply what was learned to improve patient care?

1. Medication:
2. Aripiprazole 10 mg PO daily:
3. Safe dose range: 2-30 mg/day
4. IndicationsRow1: Bipolar disorder , Schizoaffective disorder, and adjunct for depression
5. Mechanism of actionRow1: Partial dopamine (D2) and serotonin (5-HT1A) agonist; serotonin (5-HT2A)
6. Expected Side EffectsRow1: Akathisia • Anxiety • Insomnia • Weight gain • Orthostatic hypotension
7. Assessments ResponsibilitiesRow1: • Monitor mood/behavior changes • Assess for EPS • Monitor weight and glucose • Suicide risk assessment
8. Medication_2:
9. Alprazolam 05 mg PO BID:
10. Safe dose range_2: 0.25-4 mg/day
11. IndicationsRow1_2: Anxiety
12. Mechanism of actionRow1_2: Enhances GABA CNS depression
13. Expected Side EffectsRow1_2: * Dizziness * Dependence * Sedation * Respiratory depression
14. Assessments ResponsibilitiesRow1_2: • Monitor respiratory rate • Assess level of consciousness • Fall precautions • Avoid alcohol/opioids
15. Medication_3:
16. Safe dose range_3: 5-10 mg q4-6h, Acetaminophen: 3,000-4,000 mg/day
17. Therapeutic Class Pharm Class: Opioid agonist + non-opioid analgesic
18. IndicationsRow1_3: Moderate to severe pain
19. Mechanism of actionRow1_3: Binds mu-opioid receptors → blocks pain perception.
20. Expected Side EffectsRow1_3: • Respiratory depression • Sedation • Hypotension • Constipation
21. Assessments ResponsibilitiesRow1_3: Monitor RR (<12 is concerning) • Monitor LOC • Monitor total acetaminophen dose • Have naloxone available
22. Medication_4:
23. Safe dose range_4: 750-3,000 mg/day
24. Therapeutic Class: Mood stabilize
25. IndicationsRow1_4: Bipolar disorder
26. Mechanism of actionRow1_4: Increase GABA level in the brain.
27. Expected Side EffectsRow1_4: Sedation GI upset Hepatotoxicity
28. Assessments ResponsibilitiesRow1_4: Monitor ammonia level if confuse, Monitor platelets Monitor liver function test
29. Most Important FindingsRow1: Decrease respiratory rate Hypotension Decrease level of consciousness Positive opioid/benzo screen
30. Clinical SignificanceRow1: Indicates opioid + benzodiazepine toxicity → CNS and respiratory depression.
31. Medical History:
32. Home Meds:
33. Anxiety Bipolar Depression Schizoaffective disorder:
34. Pharm ClassificationAripiprazole 10 mg PO daily Divalproex 500 mg XR 2 tabs PO BID Alprazolam 05 mg PO BID: * Benzodiazepine * Mood stabilizer * Atypical antipsychotic
35. PolypharmacyRow1: Yes
36. RationaleRow1: The pt is taking multiple CNS depressants drugs which increases risk of respiratory depression.
37. Medication InteractionsRow1: Alprazolam + Hydrocodone
38. RationaleRow1_2: Additive CNS and respiratory depression → high overdose risk.
39. InterpretationRow1: Worsened
40. Clinical Significance: Positive benzo/opioid, possible elevated acetaminophen ( if elevated)
41. Pharmacology Reasoning:
42. Most Important DataRow1:
43. Clinical SignificanceRow1_2:
44. As you complete the headtotoe assessment you notice these findings:
45. Most Important DataRow1_2:
46. Clinical SignificanceRow1_3:
47. Nurse ResponseRow1:
48. Most Important DataRow1_3:
49. Clinical SignificanceRow1_4:
50. Nurse ResponseRow1_2:
51. Most Important DataRow1_4:
52. Clinical SignificanceRow1_5:
53. Metabolic Panel:
54. Metabolic PanelRow1:
55. Ca:
56. Hematology Complete Blood Count CBCRow1:
57. Misc:
58. MiscRow1:
59. Salicylates:
60. Acetaminophen:
61. Lipase:
62. Lactate Ven:
63. Hgb A1C:
64. Diagnostic Result:
65. ExpectedWBC:
66. ImprovedWBC:
67. WorsenedWBC:
68. ExpectedNeutrophils:
69. ImprovedNeutrophils:
70. WorsenedNeutrophils:
71. ExpectedHemoglobin:
72. ImprovedHemoglobin:
73. WorsenedHemoglobin:
74. ExpectedCreatinine:
75. ImprovedCreatinine:
76. WorsenedCreatinine:
77. Expected for benzohydrocodone:
78. Improved for benzohydrocodone:
79. Worsened for benzohydrocodone:
80. ExpectedAcetaminophen:
81. ImprovedAcetaminophen:
82. WorsenedAcetaminophen:
83. Priority ProblemRow1: Opioid-induced respiratory depression
84. Pathophysiology in Own WordsRow1: Opioids attach to areas in the brainstem that control breathing, which slows down or stops breathing, leading to low oxygen levels and reduced consciousness.
85. Provider Orders:
86. RationaleEstablish peripheral IV 09 NS 1000 mL IV bolus Naloxone 004 mg IV May repeat every 23 minutes until consistently awake Use 04 mg ampule of 1 mL and add 9 mL of 09 NS in 10 mL syringe for dose of 004 mg1 mL: Access for emergency medications Treat hypotension Reverses opioid effects
87. Expected OutcomeEstablish peripheral IV 09 NS 1000 mL IV bolus Naloxone 004 mg IV May repeat every 23 minutes until consistently awake Use 04 mg ampule of 1 mL and add 9 mL of 09 NS in 10 mL syringe for dose of 004 mg1 mL: Rapid medication administration Improved BP Improves respiratory rate, and increased LOC
88. Medication_5:
89. Expected Assessment Findings09 NS 1000 mL IV bolus:
90. How Long Before Evident09 NS 1000 mL IV bolus:
91. Rationale09 NS 1000 mL IV bolus:
92. Expected Assessment FindingsNaloxone 04 mg IV May repeat every 23 minutes until consistently awake:
93. How Long Before EvidentNaloxone 04 mg IV May repeat every 23 minutes until consistently awake:
94. RationaleNaloxone 04 mg IV May repeat every 23 minutes until consistently awake:
95. Medication_6:
96. Naloxone:
97. Safe dose range_5:
98. Therapeutic Class Pharm class:
99. IndicationsRow1_5:
100. Mechanism of actionRow1_5:
101. Expected Side EffectsRow1_5:
102. Assessments ResponsibilitiesRow1_5:
103. MedicationRow1:
104. Time frame to AdministerRow1:
105. Show WorkRow1:
106. Volume to AdministerRow1: 1 mL
107. Nursing Priority: Airway and breathing
108. Priority InterventionsRow1: • Administer naloxone • Continuous pulse oximetry • Monitor RR every 2–3 minutes • Administer oxygen • Monitor BP
109. RationaleRow1_3: To ensure the patient's airway and breathing are supported, reverse the opioid's effects, and maintain adequate oxygenation and blood pressure.
110. Expected OutcomeRow1: • RR > 12 • Awake and responsive • O2 saturation > 94%
111. Assessment Data:
112. ImprovedT 984 F369 C oral:
113. No ChangeT 984 F369 C oral: X
114. DeclinedT 984 F369 C oral:
115. ImprovedP 72 regular: X
116. No ChangeP 72 regular:
117. DeclinedP 72 regular:
118. ImprovedR 18 regular: X
119. No ChangeR 18 regular:
120. DeclinedR 18 regular:
121. ImprovedBP 11065 MAP 80: X
122. No ChangeBP 11065 MAP 80:
123. DeclinedBP 11065 MAP 80:
124. ImprovedO2 sat 96 room air: X
125. No ChangeO2 sat 96 room air:
126. DeclinedO2 sat 96 room air:
127. Improved510 sharp ache in the left thigh:
128. No Change510 sharp ache in the left thigh: X
129. Declined510 sharp ache in the left thigh:
130. ImprovedPupils 3 mmbrisk reactive to light: X
131. No ChangePupils 3 mmbrisk reactive to light:
132. DeclinedPupils 3 mmbrisk reactive to light:
133. ImprovedAwake and follows verbal commands: X
134. No ChangeAwake and follows verbal commands:
135. DeclinedAwake and follows verbal commands:
136. Current Status: Improved
137. Pharmacologic Recommendations if applicable: • Avoid concurrent benzo + opioid use • Consider non-opioid pain management • Reassess anxiety treatment
138. Rationale: To prevent future respiratory depression
139. medical record: Patient presented with decreased LOC and respiratory depression. RR below normal and hypotensive. Positive for benzodiazepine and opioid use. IV established. 0.9% NS bolus initiated. Naloxone 0.04 mg IV administered and repeated for total of 0.16 mg. Patient became alert, RR improved to 18, O2 saturation 96% on room air, BP stabilized at 110/65. Patient remains under close monitoring for re-sedation.
140. Reflection Question:
141. Nurse ReflectionAs you worked through this simulation how did it make you feel: It makes me feel nervous at first but moving forward it got interesting.
142. Nurse ReflectionWhat did you already know and do well on this simulation: Recognized CNS depression and prioritized airway.
143. Nurse ReflectionWhat areas do you need to developimprove: Stronger confidence in dosage calculations and toxicology interpretation.
144. Nurse ReflectionWhat did you learn How will you apply what was learned to improve patient care: Combining benzodiazepines and opioids significantly increases respiratory depression risk. Early naloxone administration saves lives.
145. Text1: Antipsychotic Atypical antipsychotic
146. Text2: Anti-anxiety Benzodiazepine