Module 5 Pharmacology Reasoning Bradycardia Suggested Answer Guidelines

Module 5 Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old Medication Categories: Concepts/Content: Antidysrhythmics Assessment ACE Inhibitors Drug-drug interactions Beta Blockers Evaluation of desired outcomes Statins Monitoring for adverse effects Oral Anticoagulants Emergency treatment of dysrhythmias Diuretics Client education Electrolytes Psychosocial support NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% X • Safety and Infection Control 9-15% X Health Promotion and Maintenance 6-12% X Psychosocial Integrity 6-12% X Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% X • Reduction of Risk Potential 9-15% X • Physiological Adaptation 11-17% X © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN I. Initial Presentation: Marilyn Fitch is a 78-year-old Caucasian woman with a history of hypercholesteremia, hypertension, and heart failure and has NKDA. She was brought in by her daughter after Marilyn complained of feeling dizzy several times this morning and then almost passed out at home. Marilyn has a six-month history of paroxysmal atrial fibrillation. Her heart rate has been regular and she has had no episodic dizziness since she had a synchronized cardioversion one week prior to this visit. Her initial VS in triage were: T: 98.9 F/37.2 C (oral) P: 52 R: 16 BP: 94/52 and O2 sat: 98% room air. Personal/Social History: Marilyn is a widow and lives alone in her own home. She denies smoking and admits to drinking one glass of wine with her dinner. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: • Hypercholesterolemia Hypertension Heart failure • Dizziness/ almost passing out • 6-month paroxysmal A fib • Synchronized cardioversion • Pulse of 52, BP 94/52 • All of these are risk factors (especially when combined) for heart attack and stroke • Concerning signs of heart rhythm changes • Vitals of low HR and Low BP, usually if one of these two vitals changes, the other will increase to compensate. RELEVANT Data from Social History: Clinical Significance: • Widow and lives alone • Drinking wine with dinner • Shows the pt doesn’t have much of a support system, and there could be psychosocial aspects to include in her care • Drinking 1 glass of wine with dinner is usually ok, in a healthy individual. Since she has heart problems, cholesterol issues and hypertension, she should restrict alcohol use. 2. What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these medications? (Which medication treats which condition? Draw lines to connect) Medical History (PMH): Home Medications: Hypercholesteremia Apixaban 2.5 mg po bid Hypertension Captopril 100 mg po BID daily Heart failure Amiodarone 100 mg po bid Atrial fibrillation Hydrochlorothiazide 50 mg po daily Atorvastatin 10 mg po daily Carvedilol 6.25 mg po bid 3. List each home medication from the scenario and answer the following: (NCLEX Pharmacologic and Parenteral Therapies) Home Medication : Pharm . Class: Indication(s): Mechanism of Action In OWN WORDS: Body Syste m Impacte d Common Side Effects: (1- 3) Nursing Assessments: Apixaban 2.5 mg po bid Anticoagulant Decreases risk of stroke/systemic embolism associated with nonvalvular atrial fibrillation It’s a highly selective and reversible inhibitor of factor Xa. It prevents the conversion of prothrombin to thrombin. CV, HEMA -Bleeding. Symptoms may include: nosebleeds bruising more easily heavy menstrual bleeding bleeding of your gums when you brush your teeth Assess patient for symptoms of stroke or peripheral vascular disease periodically during therapy. Assess for increased bleeding due to anticoagulant therapy Captopril 150 mg po daily Antihypertensive Hypertension, HF, LVD after MI, diabetic nephropathy, Supresses RAAS, inhibits ACE but preventing Angiotensin I from converting into angiotensin II CNS, CV, GI, GU, HEMA, INTEG, RESP -Dizziness, lightheadedness, or loss of taste may occur as your body Monitor blood studies (platelets, WBC, neutrophils proteinurea adjusts to the etc..), monitor medication. BP, check or - Dry cough may Orthostatic also occur. hypotension, monitor for HF (dyspnea, jugular vein distension, weight gain, edemas, lung sounds), monitor renal studies (protein, BUN, creatinine) and renal symptoms: polyurea, oliguria, potassium. Establish a baseline before studies begin. Amiodaron e 100 mg po bid Class III antidysrhythmic Used for ventricular dysrhythmias • Mainly blocks potassium channels in the heart, affecting the action potential and cardiac rhythm. • Can also affect sodium/calcium channels and A & B adrenergic receptors. CNS, CV, EENT, ENDO, GI, GU, INTEG, -Cough. -dizziness, lightheadedness, or fainting. Monitor: -electrolytes -Thyroid function tests MS, RESP. -fever (slight) -CNS symptoms -numbness or (confusions,depr tingling in the esssion) fingers or toes. -hypothyroidism -painful breathing. symptoms -sensitivity of the -hyper- skin to sunlight. thyroidism symptoms -pulmonary toxicity -monitor cardiac rate,respiration, rhythm, etc. -assess vision throughout -assess for Steven johnsons syndrome Hydrochlor o thiazide 50 mg po daily Thiazide Diuretic Helps manage mild-moderate hypertension. Tx of edema assoc. with HF, renal dysfunction, cirrhosis, glucocorticoid therapy, estrogen therapy. Inhibits sodium reabsorption in the distal tubule. Promotes excretion of chloride, potassium, hydrogen, magnesium, phosphate, calcium and bicarb. CNS, CV, GI, DERM, EENT, ENDO, HEMAT, MS, METAB nausea, vomiting, loss of appetite; diarrhea, c onstipation; muscle spasm; or. dizziness, headache. -Monitor BP, intake, output, and daily weight and assess for edema. -Monitor electrolyte and renal labs. -Monitor for signs of electrolyte imbalance, specifically potassium. -Assess for allergy to sulfonamides. -Monitor for ˆglucose,ˆbilirubi n, ˆcalcium, ûric acid, ˆcreatinine, ^serum cholesterol/LDL/ triglycerides. Carvedilol 6.25 mg po bid antihypertensive Hypertension, HF w/ digoxin, diuretics and ace- inhibitors. Left ventricular dysfunction after MI. A Atorvastati n 10 mg po daily Cholesterol 4. Based on this patient’s home medication list, does the nurse need to address the clinical concern of polypharmacy with the primary care provider? Captopril and carvedilol are both antihypertensive medications and both suppress the CNS, so should be questioned by the prescribing doctor. 5. Based on this patient’s home medication list, are there any concerning medication interactions that the nurse needs to communicate to the primary care provider? II. Present Problem: Cardiac Telemetry Strip-Six Seconds: Regular/Irregular: Regular Interpretation: regular sinus rhythm P wave present? yes PR: yes QRS: yes Clinical Significance: Her cardiac rhythm appears to be normal, which means that her dizziness could be a result of her low & blood pressure. . Current VS: P-Q-R-S-T Pain Assessment: Denies and pain or discomfort T: 98.8 F/37.1 C (oral) Provoking/Palliative: P: 54 (reg) Quality: DENIES PAIN R: 14 (reg) Region/Radiation: BP: 94/58 Severity: 0/10 SpO2: 94% on room air Timing: 1. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT VS Data: Clinical Significance: • BP 94/58 • SpO2 94% • Although her HR is 54 and WNL, it’s on the low end. • Her BP is consistently low, and is concerning. • Her oxygenation is getting slightly worse on room air.