Nursing Unit 1 Assignment Case Study Polypharmacy.

Due 5-13-23. 1000w

Advance pharmacology.

Unit 1 Assignment Case Study Polypharmacy. This is an advanced course please use the attached book and follow the instructions below.

Case Study

Mrs. A is a 71 year old widow with CHF and osteoarthritis who has recently been exhibiting quite unusual behavior. Her daughter is concerned about her mother's ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a dementing illness. Over the last two to three months Mrs. A has become confused, easily fatigued and very irritable. She has developed disturbing obsessive/compulsive behavior constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly moldy. Her prescribed medications are:

· Furosemide 40 mg daily in the morning

· Digoxin 250 micrograms daily

· Paracetamol 500 mg, 1-2 tablets 4-hourly PRN

· Piroxicam 20 mg at night

· Mylanta suspension, 20 ml PRN

· Coloxyl 120 mg, 1-2 tablets at night

Assignment Questions and Instructions

1. Critically discuss this case study in terms of the problematic nature of this patient's pharmacological management.

2. Outline some pharmacokinetic changes in the geriatric population that may affect drug disposition.

3. Outline how changes in renal and hepatic function may affect treatment strategies.

4. In the drug regimen presented above – discuss potential side effects and potential interactions, if any?

5. Your response should include a discussion of the problems of polypharmacy as it is related to this case study and the assessment/management and educational strategies which could have been implemented to improve the outcome of Mrs. A.

Instructions

· Prepare and submit a 3-4 page paper [total] in length ( not including APA formatted title and references pages).

· Answer all the questions above.

· Support your position with examples.

Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.

Estimated time to complete: 4 hours

Sample assignment

Case Study

Mrs. A is a 71-year-old widow with congestive heart failure and osteoarthritis who has

recently been exhibiting quite unusual behavior. Her daughter is concerned about her mother's

ability to remain independent and wishes to pursue nursing home admission arrangements. She

fears the development of a dementing illness. Over the last two to three months Mrs. A has

become confused, easily fatigued and very irritable. She has developed disturbing

obsessive/compulsive behavior constantly complaining that her lace curtains were dirty and

required frequent washing. Detailed questioning revealed that she thought they were yellowgreen

and possibly moldy. Her current medications include Furosemide 40mg every morning,

Digoxin 250 mcg daily, Paracetamol 500mg to 1000mg every 4 hours as needed, Piroxican 20mg

at night, Coloxyl 120 mg to 240 mg at night, and Mylanta 20ml as needed.

Polypharmacy

Polypharmacy, or the use of more than five medications at a time, is frequently found in

the geriatric population. Most patients greater than 65 have multiple disease processes and see

multiple specialty providers to manage their medications. Polypharmacy is linked to many

geriatric patient falls and non-adherence to medication regiments. When a patient, especially

elderly, is on more than five medications a day it is difficult to remember the different times or

the patient has forgotten they took the medication and they take it again (Brown, 2016).

As a health care practitioner, to help the patient with their polypharmacy, is to address all

medications at every visit (Brown, 2016). Another way to help my patient is to review the

medication list and drug history every six months. During the review of medications on each

visit or every six months, look for medications that the patient is taking that the indication is no longer needed (Woo et al, 2015). For example, pain medication from a surgery years ago, or

supplements that may not be needed anymore. Another thing to look for during the review is

duplicate drug therapies. As a health care provider, you can also encourage and educate lifestyle

changes or non-drug therapies when able, as well as avoid prescribing unnecessary medications.

Also sometimes it’s importance to differentiate the manifestation of the aging process, which

may be the problem, not a disease process that needs to be treated (Woo et al, 2015).

Pharmacokinetic Changes in Geriatrics

Changes seen in geriatric patients are sometimes associated with the aging process.

Adults greater than 60 have normal deterioration of white brain matter causing mental changes.

While disease processes can add to the mental changes, such as Alzheimer’s and strokes, Acute

processes can also increase geriatric mental changes, such as infection and electrolyte

imbalances (Woo et al, 2015). For this patient, her confusion could be linked to her age. Other

physical changes in the geriatric population that this patient could be experiencing is changes in

sight. Visual impairments increase with age due to the loss of elasticity and lens thickening (Woo

et al, 2015).

While her confusion may be related to the aging process, but it could also be related to

the absorption and distribution of medication. In geriatric patients, lean muscle mass and total

body water also decrease. Some drugs are distributed in these places and when there is less

muscle mass or body water available the concentration can be higher due to the lower body ratio

of the geriatric patient (Woo et al, 2015). For example, this patient is currently taking digoxin, if

she is on the same exact dose she was on when she was 61, the chances of the digoxin dose

needing to stay the same is unlikely due to the change of her muscle mass and body water.

Therefore, checking levels on a regular basis is important, especially in the geriatric patient. Changes in Renal and Hepatic Functions

When it comes to changes in renal and hepatic functions in the geriatric patient, it most

often effects metabolism and excretion of the medications. In this population, the liver size

decreases and the blood flood decreases as well. Drugs that are cleared by the liver depend on the

blood flow, which means that geriatric patients usually metabolize medications slower (Woo et

al, 2015). Mrs. A’s medications may be staying in her system longer also causing her to get more

medication than she really needs.

With age the kidney’s function declines about 1% every year starting at the age of 30.

Most geriatric patients have a 50% decline in their kidney function by the age of 80. Drugs are

typically excreted through the kidneys and kidney function should be taken into consideration

when dosing medications. A decrease in kidney function and the inability to excrete the drug can

also cause long lasting medication effects (Woo et al, 2015).

Potential Drug Interactions

The potential interactions of these drugs are moderate. Furosemide is a diuretic which can

decrease the patient’s potassium and the stool softener can also decrease the patient’s potassium

through frequent stools it is important to closely monitor this patient’s electrolytes. Decreased

potassium can also put this patient at increased risks for arrhythmia’s because she is on digoxin.

It would also be important to monitor her digoxin levels to make sure she isn’t exhibiting signs

of digoxin toxicity (Drugs.com, 2017). The visual disturbances of the lace curtains could be

related to general aging or it could be signs of digoxin toxicity.

Mrs. A is also on an NSAID and an acetaminophen product that could aid in her already

compromised renal perfusion. Because she is on these medications as well as her othermedications for heart failure puts her at an even more increased risk of an adverse drug reaction.

Some NSAIDs could potentially decrease the digoxin levels in the blood (Woo et al, 2015).

Recommendations

For this patient, I recommend monitoring digoxin levels as well as electrolyte levels

frequently. I would most likely have to decrease the doses or her Lasix and digoxin, if the

digoxin level was too high and if the potassium and magnesium levels were too low. I would also

consider a different type of medication for the treatment of osteoarthrosis. The patient is also on

a couple of medications for constipation, gas, and heart burn. For this, I would recommend life

style change such as diet. Mrs. A should avoid spicy foods or foods that cause her gas or

indigestion. I would also recommend her trying to walk 30 minutes a day and drink more water

to help prevent constipation. If the lifestyle changes are ineffective I would try prune juice or a

gentle stool softener over a laxative.

References

Woo, T., Wynne, A., & Wynne, A. (2015). Pharmacotherapeutics for nurse practitioner

prescribers.

Drugs.com (2017). Drug Interactions. Retrieved January 22, 2017, from

https://www.drugs.com/interactions-check.php?drug_list=883-0,1881-0,2365-

11843,1146-676,145-8681,11-12

Brown, L. (2016). Untangling polypharmacy in older adults. Medsurg Nursing, 25(6), 408-411.

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