Respond to 2 people. Heidi and Pearl, by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
Week 1 Discussion
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It is important when prescribing medication to consider a patient’s medical history and current medication regimen. The way that a patient responds depends on numerous factors that all need considered to provide safe care.
At a previous job I worked in the surgical department of a rural, critical access hospital. We had an orthopedic surgeon who performed numerous joint replacements each week. As with almost any surgery, patients need to stop anticoagulation therapy at least five days prior to the procedure unless otherwise indicated by the cardiologist. We had a female patient with a history of atrial fibrillation and pulmonary embolism, taking coumadin, scheduled for a knee replacement. Our protocol in surgery was to have patients hold anticoagulants five days prior to surgery after consulting the cardiologist, getting cardiac clearance, and orders for holding anticoagulants if permitted to do so.
Coumadin is quick to be absorbed and has a half life of 1.5-2 days (Rosenthal & Burchum, 2018, p. 460). The way that coumadin works in the body is by blocking the vitamin k dependent clotting factors (RxList, n.d.). The patient described needed to be on anticoagulant therapy for prevention of blood clots, but for surgical purposes could be dangerous to continue. The patient was relatively healthy with no comorbidities other than the atrial fibrillation and history of a prior pulmonary embolism. The patient’s kidney function was good, her PT/INR were in therapeutic range, and she was in her mid 50’s. This patient did have decreased mobility, which is why she was undergoing a total knee replacement, which put her at risk postoperatively for a DVT or embolism.
Personalized Plan of Care
The first plan of care that I would address is to obtain cardiac consultation and clearance by the patient’s cardiologist. I would plan care based on their recommendations on how long to hold anticoagulant therapy. One option would be to dose the patient with a Lovebox bridge, that is short acting, so that they can still have some type of anticoagulant in their system and it won’t affect the surgical procedure. Atrial fibrillation is a major factor that increases the risk for a blood clot (Douketis & Lip, 2019). Interruption of anticoagulant therapy could be dangerous for a person with atrial fibrillation. Collaboration with anesthesiologist, cardiologists, and surgeons is needed for best practice consideration for holding anticoagulants. A decrease in mobility is another consideration. Patients who undergo joint replacement are less mobile than others. Anticoagulants should be started as soon as they can be safely administered after the procedure to reduce the risk of clot formation. Other non-pharmacological interventions are SCD sleeves during surgery and starting physical therapy quickly after surgery.
Douketis, J. D., & Lip, G. Y. (2019, May 21). UpToDate. Retrieved from https://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne's Pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
RxList. (n.d.). Coumadin (Warfarin sodium): Uses, dosage, side effects, interactions, warning. Retrieved from https://www.rxlist.com/coumadin-drug.htm#clinpharm
1 day ago
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Pharmacodynamics and Pharmacokinetics
Healthcare providers need to know pharmacokinetics and pharmacodynamics of medications and the effects they have on patients. Drugs can have many effects reaction to the body. The relationship between the drug and the body is that the body affects the drugs and the drug affects the body. Pharmacodynamics is how the drug initiates its therapeutic or toxic effects at the cellular and systemic levels and pharmacokinetic is the process through which the drug is absorbed, distributed and eliminated from the body (Arcangelo, Peterson, Wilburg, & Reinhold, 2017).
Scenario of selected patient
Mrs. Fisher, an 80-year-old patient was admitted to the hospital for a fall. Prior to the fall, she has been having diarrhea from a course of antibiotics for urinary tract infection treatment. Pt was unable to rest at night due to her frequent diarrhea. Her caregiver stated that Mrs. Fisher took one tablet of Benadryl to help her sleep at night and requested for more sleeping medication be given to her at night. Ambien 5mg one tablet by mouth, at bedtime was prescribed by the provider. Patient was also given hydrocodone 5/325 mg to help with her pain from fall. Ambien was given the first night it was ordered. On the second night of taking the medication, patient started showing some side effects which may be from the medicine. Mrs. Fisher became agitated, confused and combative. The provider was notified of the patient’s confusion and agitation and all medication patient took while in the hospital. The provider ordered Ativan 0.5mg to be given intravenously to help with agitation. Mrs. Fisher after getting the Ativan 0.5mg ordered seems like it made her agitation worse.
Factors influencing pharmacokinetics and pharmacodynamics
Healthcare providers need to apply the knowledge of pharmacokinetics to drug therapy which will help to maximize beneficial effects while minimizing harm (Rosenthal & Burcham, 2018). Many factors influence the pharmacodynamics and pharmacokinetics of medications, including the patients age, gender, and actions. The Food and Drug Administration recommends the dose of Ambien for geriatric women to be 5mg for immediate release and 6.25mg for Ambien CR extended release (Ulrich, 2009). Side effects from Ambien can present as sleepwalking, sleep driving, increased falls, disorientation, anxiety, and delirium which is most common with elderly (Rosenthal & Burcham, 2018). Mrs. Fisher took both hydrocodone, Ativan and Ambien. The interaction between these medications could have easily caused her increased confusion and agitation. According to Markota, Rummans, Bostwick, and Lapid (2016), the American Geriatrics Society has placed all benzodiazepines in the list of drugs that should be discouraged in patients over the age of 65. This is due to older adults have increased sensitivity to benzodiazepines and reduced metabolism of long acting agents, resulting in an enhanced danger of cognitive impairment, delirium, falls, fractures and car accidents. American Geriatric society also recommends long acting benzodiazepines such as Xanax instead of short acting such as Ativan if they must be prescribed (Markota et al., 2016).
Plan of care. Nonpharmacological techniques such as removing background noise should be encouraged to relieve anxiety and encourage sleep in the elderly. Pain management should be adequately treated to reduce discomfort. Arcangelo et al. (2017), recommends Haldol over any benzodiazepines due to drugs such as valium could have a half-life of about 70 hours in the elderly. It is recommended to give psychoactive medications for the behavioral disturbance resulting from the somatic conditions, such as aggressiveness only for a limited time. Home medications also needs to be considered in other to address polypharmacy which is very common with the older population.
When caring for the elderly, the providers needs to understand the physiological changes that occur in the body. It is important to review medications that are prescribed to the patient before prescribing anything new. Patient education is key to providing care. The patient and family must understand the need to bringing all their medications or list of all patient’s medications to all medical appointments. Teaching must also be provided for the patient to report any changes, signs or symptoms that can be seen in new medications.
Arcangelo, V. P., Peterson, A. M., Wilburg, V., & Reinhold, J. A. (2017). Pharmacotherapeutics
For Advanced Practice: A Practical Approach. (4th Ed.). Wolters Kluwer Lippincott
Williams & Wilkins.
Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine use in
Older adults: Dangers, management, and alternative therapies. Mayo Clinic Proceedings,
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice
Providers. St. Louis, MO: Elsevier.
Ulrich, K. (2009). Pharmacokinetics and drug metabolism in the elderly. Drug Metabolism
Reviews, 41(2), 67-76.
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