Pharmacology Scenario 7: Jermaine Jones

Pharmacology Scenario 7: Jermaine Jones Documentation Assignments 1. Document your initial focused assessment data of Jermaine Jones (who took an antidepressant drug combined with an anxiolytic drug), including orientation, level of consciousness, pain assessment, and vital signs. The patient stated he did not have any pain. He was alert and oriented x 3 (did not know the date) GCS of 13. Heart rate (95), RR (12), SpO2: (92), Temp: (99), blood pressure (125/74). 2. Document any assessment data related to Jermaine Jones’ diagnosis of depression. The patient was diagnosed of depression 2 years. He stated that he did not have any thoughts about harming himself, He stated he is sad about his father passing away a year ago and is having difficulty coping with is. He also stated his decreased appetite and notice he has lost weight without trying. He is taking an antidepressant medication every day to manage his diagnosis. 3. In the nurses’ notes, document the medication reconciliation information for Jermaine Jones. Include the medications he was taking prior to admission, any medications given during the scenario, and the medications he will be taking at home. Note any drug–drug interactions. There was no medication given during this scenario. Patient stated he does not take over the counter medications or any herbal supplements. He takes sertraline 50 mg daily as prescribed for depression, which he took this morning. He will continue to take the medication when discharged, but is not leaving with any new prescribed medication. Before admission, the patient has been drinking alcohol, and took his prescribed medication along with a 0.5 mg of alprazolam, his wife medication. Mixing these two medications along with alcohol caused him to have a decreased LOC as these medications and alcohol are all CNS depressants. 4. Document the information you provided to Jermaine Jones and his wife regarding adverse drug effects when combining SSRIs, benzodiazepines, and alcohol. Education to the patient was given, the symptoms you are experiencing are due to mixing alcohol, an antidepressant and benzodiazepine. This combination is potential lethal, and you should avoid this in the future. 5. Document your report to the provider in the situation-background-assessmentrecommendation (SBAR) format. S- Mr. jones was admitted from the emergency department after mixing alcohol with sertraline andalprazolam. His wife was concerned about his mental condition B - The patient was diagnosed with major depression 2 years ago and is not coping well with his father’s death 1 year go. He said he took the alprazolam for anxiety and says he shouldn’t have been drinking so much and that he drinks 3 beers. A- He is alert and oriented x 3 (does not know the date). Vital signs are within normal range. GCS of 13. No pain and NS running at 100 mL/hr R- I have assessed him and educated the patient about his drug interactions and also performed a medication reconciliation.