NURS 6521 Advanced Pharmacology Discussion
WEEK 1 :Diabetes Care in the Elderly
Ms. X is an 86-year-old white obese female who presented to the ED with altered mental status and weakness last week. Ms. X has a history of hypertension, UTIs, and type two diabetes mellitus (DM). Ms. X lives next door to her daughter but otherwise is very independent and active. Upon arrival to the ED, her blood glucose level was in the 30’s. The ED physician ordered a D10 drip, and the patient was sent to the medical intensive care unit for monitoring. Before presenting to the ED, Ms. X was seen at her primary care provider’s office and was prescribed Bactrim for a probable UTI (no urine specimen was obtained) and continued to take her prescribed medications which included Glipizide. NURS 6521 Advanced Pharmacology Discussion
Pharmacokinetics is how a drug moves through the bodily systems, is processed, absorbed, and excreted. Pharmacokinetics also entails the study of the onset and duration of a drug in the body and enables the provider to find the therapeutic window, the targeted therapeutic response without toxic side effects (Arcangelo, Peterson, Wilbur, & Reinhold, 2017)
Pharmacodynamics is what the administered drug does to the body, studying the biochemical, physiologic, and molecular effects of a drug within the body. Pharmacodynamics can be influenced by disease, aging, and polypharmacy (Farinde, 2016).
Ms. X took two prescribed drugs that interfered with each other, Bactrim and Glipizide. Bactrim, an antimicrobial, prescribed for a suspected UTI, and Glipizide was a daily maintenance medication used to control her DM. Ms. X had several factors that influenced the pharmacokinetics and pharmacodynamics. First, Ms. X is 86. Elderly patients have reduced renal and hepatic function causing a diminished metabolism often causing an elevated drug level leading to toxicity. Patients over the age of 65 are seven times more likely to be hospitalized due to unintentional overdosing (Woo & Robinson, 2016).
Second, Ms. X took a potentially harmful combination of drugs. Glipizide is a sulfonylurea. An adverse effect of this drug is hypoglycemia, specifically in the elderly with renal impairment or hepatic dysfunction. Glipizide has a long half-life and is not recommended in older adults as it could build up to toxic levels. A new concern is the risk of hypoglycemia when sulfonylurea drugs are mixed with the concurrent use of antibiotics (Woo, Kim, Sung, Cho, & Park, 2012). Bactrim should be used cautiously in elderly patients, particularly in those with decreased renal function. Combining Glipizide and Bactrim can cause increased levels of Glipizide in the body due to the competition of the drugs to be bound to proteins (RXList, n.d.).
The mixture of a DM, reduced renal and hepatic function, and the combination of a sulfonylurea and an antibiotic created the perfect storm for Ms. X to have a hypoglycemic episode. Hypoglycemia is the most common medication complication seen in elderly patients and can be an even bigger problem than cardiovascular disease in some sub-groups in the elderly (Nainggolan, 2013). NURS 6521 Advanced Pharmacology Discussion
DM is becoming one of the most chronic diseases in the world with the growing elderly population. An appropriate plan of care for patients like Ms. X should include frequent assessments, especially with medication evaluations and possible drug interactions. Treatment plans should remain simple, with few drugs as possible and if drugs are required, utilize the smallest dose possible to start and increase only if needed and at a slow rate. All patients should have a thorough physical assessment as well as baseline liver and kidney function tests performed before any drug regimen is started (Yakaryilmaz & Ozturk, 2017). Ms. X needs to have her medications re-evaluated and changed to those that are compatible with impaired organ function. She and her daughter need to be educated on possible drug interactions as well as lifestyle changes that can be made to help reduce the number of drugs needed on a daily basis.
WEEK 2 :Ethical Challenges in Treating Friends and Family
Scenario #3 describes a nurse practitioner writing a prescription for her husband who is not a patient, for a narcotic. This scenario is troubling on multiple levels. To be a judicious provider, it is the advanced practice nurse’s responsibility to perform an extensive physical and review the patient’s history before a diagnosis is obtained and a treatment plan devised. Writing prescriptions involves the responsibility of being confident in assessing the patient and ordering or administering the correct diagnostic tests and measurements, then creating a plan of care based on these factors (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Ethical Issues
Treating family or friends involves several ethical dilemmas, and increase in severity the closer the relationship is (husband/wife). Conflict of interest arises when the provider has a dual role and loses objectivity, often treats outside their scope of practice, and potentially puts the patient at risk. Issues of non maleficence and beneficence are introduced in this type of situation due to the fact proper evaluations may not be completed or appropriate diagnostic testing performed (Gold, et al., 2014). When prescribing narcotics, proper assessments need to be completed and recorded on the patient’s chart. Clinically validated tools such as SOAPP (Screener and Opioid Assessment for Patients in Pain) are important to utilize to develop a plan of care, proper dosing, and assessing the patient’s level of tolerance (Woo & Robinson, 2016).
The advanced nurse practitioner’s responsibility entails adhering to a standard of care; if you treat a treat a family member, ethically, it should be done in the same manner as a patient seen in the clinical setting. This standard of care includes ordering any necessary testing and providing documentation of an exam and the thought process behind the clinical decisions made (Zilber, 2016). The conscientious provider will refer the patient to an urgent care location, colleague, or an emergency department if narcotic prescriptions are warranted.
Legal Implications
Legally, if a provider issues a narcotic to a family member, the state licensing board can become involved to review the provider’s prescribing practices. Treating family members not only raises ethical flags, but legal issues including potential billing issues, insurance claims, and possible Medicare improprieties (Gold, et al., 2014). With the increasing national opioid crisis, advanced nurse practitioners need to be ever mindful of their prescribing power. While all states may vary on the limits to the power of narcotic prescription authority, most have adopted new rules and regulations related to the prescribing of opioids and can be located on each state board website. If the practitioner is found non compliant or not acting in accordance with the law, they could potentially lose their license or face legal proceedings (Stokowski, 2018). NURS 6521 Advanced Pharmacology Discussion
Ramifications
This scenario involves several parties. The patient potentially could have a substance abuse problem that the provider is enabling; this could result in overdose, impaired driving, and the vicious addiction cycle. The perpetual access to drugs and substance abuse affects family members, community safety, increased patient mortality and the increase in insurance premiums due to potential high-risk behavior resulting in injury. The pharmacist is putting their license on the line providing the patient with narcotics because they are administering the provider’s script on good faith that it was prescribed under the appropriate standard of care. If this prescription was a one-time dose, without proper assessments or referral to appropriate specialties, the pain could be a sign of something that needs further medical attention outside the advanced practice nurse’s scope of practice or specialty.
Strategies
First, I would approach my superior. I would not approach the co-worker writing the prescription directly. I would review with my supervisor what I saw, and voice my concerns as this is not only an ethical violation but a legal issue as well. If I did not feel comfortable going to my superior and felt my job may be in jeopardy, I would look for other avenues such as an ethics hotline or an anonymous risk management number. I would ensure what I saw was legitimate and could be proven with prescription verification (Philipsen & Soeken, 2011).
If I had no options available to me, I would research how to contact the board of nursing discretely. Due to the opioid crisis making the national spotlight with laws and regulations recently enacted, this type of scenario would more than likely be handled without much of the reporter’s participation. Prescriptions are easily tracked through state databases and the provider number. If this was indeed a blatant abuse of power and an addiction situation, or a one-time lapse in judgment, it is up to the facility’s administration and the board of nursing to distinguish.
WEEK 3 :Pharmacotherapy with Cardiovascular Drugs
Cardiovascular disease is commonly encountered when caring for patients both within the inpatient and outpatient settings. Advanced practice nurses will often encounter patients with multi-pharmacy and multi-physician requiring medication review as well as medical history review and exam. NURS 6521 Advanced Pharmacology Discussion
Scenario 2 presents with patient HM who has a history of atrial fibrillation, TIAs, type 2 diabetes, hypertension, hyperlipidemia, and ischemic heart disease/failure. Current medications include Warfarin 5mg MWF and 2.5mg T, TH, Sat, Sun, Aspirin 81mg/day, Metformin 1000mg BID, Glyburide 10mg BID, Atenolol 100mg/day, and Motrin 200mg 1-3 tablets every 6 hours as needed.
Influencing Factor
Behaviors by individual patients can and do often affect medications and their actions. One such action is the use of over the counter vitamins and minerals. Vitamins and minerals can often compete for receptors or negate an active ingredient or potentiate the effects. For example, calcium products have been documented to affect the serum levels of atenolol and other beta blockers leading to subtherapeutic levels and poor bioavailability (Drugs.com, 2018). Warfarin can also be affected by multiple over the counter vitamins and minerals. Vitamin K is an antagonist to warfarin and can affect therapeutic levels and INR results. Vitamin A, fenugreek, chamomile, cranberry, and Ginkgo Biloba are just a few known to inhibit therapeutic levels of warfarin by interacting with different processes within the pharmacokinetics and pharmacodynamics of the medication (Beikang, Zhen, Zhong, 2014).
Treatment Plan
Initially a review of medications demonstrates the need to discontinue the aspirin and NSAID – ibuprofen. Both drugs demonstrate blood thinning action potentiating the affect of warfarin in the blood possibly leading to excessively thin blood and increased risk of bleeding. Aspirin and ibuprofen both also interact with glyburide by again potentiating the hypoglycemic effect on the body leading to increased risk for hypoglycemia (Drugs.com, 2018) Ibuprofen can also decrease the efficacy of Atenolol (Epocrates, 2018). Next due to the patients increased risk for ASCVD and diagnosis of diabetes, the American Heart Association and the American College of Cardiology recommends a high intensity statin therapy to reduce ASCVD risk and cardiac mortality (Lambert, 2014). Atorvastatin 40mg po daily would be appropriate to prescribe for improved patient cardiovascular event and mortality risk.
When reviewing medications, the APRN also needs to clarify if any over the counter medications are being taken to determine possible interactions while taking this time to educate on the need to discuss any new medications, prescription or OTC, with them prior to initiating for safety. Education also needs to be completed concerning compliance to regimen and the need for routine follow up due to increased risk factors and the need for warfarin monitoring of PT/INR levels with a goal of 2-3 NURS 6521 Advanced Pharmacology Discussion
In conclusion, APRNs must evaluate the whole patient, the treatment plan, weigh pros and cons, and consider multiple individualized factors when prescribing medications to each patient.
WEEK 4 :Neurological Disorder: Headaches (HA)
According to the World Health Organization (WHO), HA disorders affect at least half the adult population once a year. HAs can be classified as either primary or secondary. Primary diagnosis is achieved when all secondary diagnosis possibilities are ruled out. Examples of primary HAs are tension headaches (THA), migraines, and cluster headaches (CHA). Examples of secondary HAs are those caused by head/neck trauma, vascular disease of the cranial or cervical areas, substance abuse (including withdrawal), and diseases of the cranium to name a few (Arcangelo, & Peterson, 2013). This discussion will be focused on the pharmacotherapy of primary HAs.
Pharmacotherapy for HAs
First line therapy for mild to moderate THAs is the use of acetaminophen (Tylenol) or aspirin (ASA). These medications are to be used no more than two times per week or they risk causing chronic headaches. This situation is termed medication overuse headache (MOH). Tylenol has a max single dose of 650 mg along with a max of 3250 mg in one 24-hour period. Second line therapy for THAs is the use of NSAIDs (naproxen, ibuprofen) with or without the addition of an antiemetic (prochlorperazine, metoclopramide). If the previously mentioned interventions fail to decrease symptoms, then the practitioner may consider a barbiturate and caffeine combined with either acetaminophen or aspirin (Fiorinal, Fioricet). These combinations have a high risk for addiction and are not to be used more than three times in one month (Arcangelo, & Peterson, 2013). Paracetamol 1000 mg, ibuprofen 400 mg, and ketoprofen 25 mg were found to decrease moderate/severe THA symptoms within 2 hours of administration in a 2014 review conducted by Moore, Derry, Wiffen, Straube, and Bendtsen.
Migraines
Similar to THAs, fist line therapy in treating mild migraines is using Tylenol and ASA. If the migraine is moderate to severe, triptans (sumatriptan, zolmitriptan), as well as NSAIDs, may be used as first-line therapy. Triptans have a broad range of peak onset, duration, efficacy, and side effects that also differ on route of administration. Careful consideration of the patient and comorbidities need to be assured when prescribing triptans. If the migraine is resistant to above therapy, compounds combined with caffeine (Excedrin) or NSAIDs can be used as second-line therapy. Ergotamine derivatives may be attempted if above have failed. Third-line therapy involves the barbiturate combinations mentioned previously. Opioid combinations (Percocet, Vicodin) may be used as “rescue” therapy but are not encouraged for regular use by patients (Arcangelo, & Peterson, 2013). A 2015 literature review by Marmura, Silbersteine, and Schwedt supported the above therapies by naming triptans, NSAIDs, ergotamine derivatives along with opioids as the most effective therapy for acute migraines.
Cluster HAs
CHAs are rare and need to be consulted with a neurology specialist. Medications found to be effective in treating acute CHAs were subcutaneous sumatriptan, zolmitriptan nasal spray, and oxygen. The use of nasal spray sumatriptan, oral zolmitriptan, codeine/lidocaine nasal spray, and sphenopalatine ganglion stimulation were found to have less evidence to support their utilization. As far as decreasing exasperations, suboccipital steroid injections were found to have the strongest evidence for efficacy (Robbins et al., 2016).NURS 6521 Advanced Pharmacology Discussion
Factor: Gender
Migraine headaches can affect up to 14% of women and 6% of men. Migraines have also been found to have a close link with females in certain families (Arcangelo, & Peterson, 2013). Women are at particularly high risk for migraines before and during menopause (Martin et al., 2016). Migraines may actually decrease after the first trimester in some pregnancies. Unfortunately, triptans and the ergot derivatives are not recommended in pregnancy due to their teratogenic effects. Tylenol is seen as the safest drug to use during pregnancy, and a combination of it with codeine may be utilized infrequently while pregnant (Arcangelo, & Peterson, 2013). A 2015 study by Marchenko et al. found that triptans use during pregnancy does not seem to affect birth defects or prematurity, but the authors say further research is still needed on their effect on spontaneous abortions.
Factors that I would take into consideration when treating this patient population is to ensure individualized treatment. I would need to know if the patient suffering migraines was pregnant or planning on becoming pregnant. If so, I would conduct patient teaching on the limitations we have on prescriptions available, on using Tylenol appropriately and utilizing non-pharmacological interventions. Spiritual meditation was found to increase tolerance to migraine severity and decrease use of analgesics (Wachholtz, Malone, & Pargament, 2015). If pregnancy was not a factor and the patient was on hormone replacement, I would conduct education in that hormone replacement therapy may increase the incidence of migraines by as much as 40%. If the patient’s HAs are tied to menses, frovatriptan has been shown to be efficacious in treating these types of migraines (Arcangelo, & Peterson, 2013).
WEEK 5 : Pharmacotherapy of Neurological Disorders
Multiple disorders are incorporated into the heading neurological disorders, headaches, seizures, depression, and dementia are just a few. Headaches are a commonly encountered complaint in primary care practice.
Headaches are categorized as primary with no underlying causes and secondary with known underlying etiology. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, cluster headaches, and other primary disorders. Secondary headaches are attributed to disease processes, such as traumatic brain injury, substance withdrawal, cerebrovascular disorders, and other disorders. Each headache is individualized and experienced individually by the patient. Advance practice nurses must review symptoms, occurrence details, triggers, duration and frequency of headaches, current treatments, location of pain, and intensity. Details allow for specific diagnosis of the type of headaches leading to effective treatment.
Treatment
Multiple treatments are available for mild, moderate, and severe headaches. Goals of therapy include a reduction in frequency, severity while improving quality of life and functionality. First line treatment of mild to moderate primary tension headaches include acetaminophen, aspirin, and NSAIDS. However, these treatments must be monitored and altered for any patients with renal or liver disease or insufficiency and are to be used episodic less than 2 times per week. Second line treatment for tension type headaches include antiemetics, over the counter combination agents, such as Excedrin, and prescription butalbital/caffeine/acetaminophen medication. All headache remedies should be used infrequently to decrease the chance of medication overuse headache.
Migraine headaches are diagnosed as recurrent headaches lasting 4 – 72 hours and severe pain leading to functional limitations. Migraines can be triggered from food to hormones to lack of sleep and onset is quick pulsating with or without auras. Pathophysiology of migraines is not fully understood and is influenced by multiple factors. Treatment goals are the same for migraines as tension headaches.NURS 6521 Advanced Pharmacology Discussion First line treatment begins with NSAIDS and aspirin for acute attack treatment. Acute attacks can also be treated with over the counter medications, such as Excedrin. 2nd line for recurrent migraines not responsive to first line treatment includes triptans. Triptans, or 5-HT Receptor Agonists, work on intracranial blood flow, sensory neurons, and trigeminal terminals to decrease the symptoms of migraine. Each triptan has individual onsets, duration’s, and half-lives. Ergot derivatives, barbiturates, opioids, and steroids are also options for acute attack treatment. Prophylactic treatment is initiated to prevent to occurrence frequency and severity of migraines when patients experience more than 2 headaches a week and quality of life/functioning is altered (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Treatment with anticonvulsants, ACE, ARBs, beta blockers, triptans, CCBs, and antidepressants have all been shown to assist in migraine prevention. Prophylactic treatment must be individualized and based on efficacy and tolerance by the patient, it may take different therapies for each patient. Headache treatment can be difficult and problematic as a generalized treatment plan will not be sufficient to treat every patient (Affaitati, Martelletti, Lopopolo, et. al., 2017).
Genetics
Headaches, such as migraines and other types have been linked to familial occurrence and hereditary. A study from China in the journal, Clinical Neurology and Neurosurgery, demonstrated high prevalence of headaches in comparison with the general population making familial ties a very influential factor aiding in diagnosis (He, Yu, Liu, Yang, et. al., 2016) Advance practice nurses should review family history as well as medical history when evaluating a patient for recurrent headaches seeking treatment.
WEEK 6 :Pharmacotherapy of Endocrine and Musculoskeletal Disorders
Osteoarthritis is a common disorder frequently encountered in primary care practice affecting approximately 30 million patients within the U.S. (Centers for Disease Control and Prevention). Advance practice nurses must be familiar with diagnosing and treating this ailment effectively in the outpatient setting.
The Disease
Osteoarthritis is characterized by degeneration of articular joint cartilages, decreasing production of synovial fluid, and ultimately impairing function of the affected joint (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Diagnosis is based on the American Collage of Rheumatology (ACR) diagnostic criteria with further specificity based on the affected joint. General symptoms include pain, stiffness, crepitus, tenderness, and pain with movement or that radiates. Physical symptoms include Heberden’s nodules to distal joints, joint effusion or enlargement, decreased range of motion, joint contractures, and progressive worsening.
Initiating Treatment
Osteoarthritis treatment goals are to decrease pain/discomfort, improve functionality, and prevent further progression of the disorder. Severity at the time of diagnosis can lead the prescribers plan of treatment and the level of aggressive treatment.
First line treatment in mild to moderate OA begins with nonpharmacological therapies and Acetaminophen 1GM every 6 to hours. Acetaminophen has very few interactions and is very effective in mild analgesia and anti-inflammatory. Alternative medications that can be used as first line include over the counter products, such as Icy Hot or capsaicin products. Prescription topical NSAIDS such as Diclofenac can also be used as adjunct therapy for localized improvement. NURS 6521 Advanced Pharmacology Discussion
Second line treatment includes NSAIDs. NSAIDs are classified due to their individual structures and provided both analgesia and anti-inflammatory properties. NSAIDs block pain and inflammation mediators as well as interfering with COX 1 & 2 enzymes. Some NSAIDs are enzyme specific and others are nonspecific leading to more adverse effects with medication use. Common NSAIDs used are ibuprofen, Celebrex, Diclofenac, and Naprosyn. Pt response to NSAIDs vary and each individual patient may react differently to medication within the same class.
Third line treatment for patients not tolerating or ineffective with the first line treatment, pain analgesics, opioid or nonopioid pain medications can be initiated. Tramadol, Tapentadol are mu opiate receptor agonists that block ascending pain pathways decreasing the sensation of pain and affecting uptake of serotonin and norepinephrine leading to pain control. Duloxetine is another third line medication effecting serotonin and norepinephrine interrupting pain pathways in the brain. Duloxetine may take up to 4 weeks to show improvement. Finally, intra-articular corticosteroids can be injected into the joint in nonresponsive cases or acute flare-ups but should be used judiciously.
Individual Factor
Alcoholism and poor liver function can affect the treatment of OA by altering the pharmacokinetics and pharmacodynamics of medications within the body. NSAIDs are already an established initiator of GI complications such as GI bleed, however a patients excessive alcohol use can increase the risk for severe GI toxicity (Neutel & Appel, 2000). The most common affects of NSAIDS toxicity include GI concerns and renal and liver alterations of function.
Liver failure has also been reported with acetaminophen use in alcoholic patients. Patients using acetaminophen for therapeutic use that consume alcohol can lead to hepatic failure, necrosis, and death (Kuffner, Green, Bogdan, Knox, et.al., 2007). Acetaminophen is metabolized within the liver and the CYP enzyme system. CYP2E1 induction and alcohol use results in increased accumulations and hepatotoxicity from nontoxic dosage levels (Tanaka, Tamazaki, & Misawa, 2000).
The importance of medical, familial, and social review cannot be stressed enough when prescribing medication therapy for patients as all individual factors specific to each patient can and does effect compliance, adverse reactions risk, and efficacy of therapy. Osteoarthritis treatment is a progressive disorder affected by multiple aspects of the patient’s lifestyle requiring specificity and individualized treatment.NURS 6521 Advanced Pharmacology Discussion
WEEK 8 : Depression
When patients experience changes in their behavior, mood swings, changes in thoughts, and an overall decline in their health, they will be diagnosed with depression, which is a chronic mental disorder. Depression can range from mild to severe disease. It disrupts a person’s ability to handle day to day tasks and the ability to enjoy life (Fekadu, Shibeshi, & Engidawork, 2017). The occurrence of depressed mood, loss of interest in activities that were once pleasurable in the past for at least two weeks are some characteristic signs of major depressive disorder (MDD). The previous symptoms will be joined by at least four of the following indicators, including recurrent thoughts of death or suicide, changes in weight, loss of appetite, changes in sleep patterns, feeling of irrelevance or guilt, problems concentrating, altered psychomotor activity, and difficulty making decisions. Patients may experience a majority of the symptoms nearly every day and cause significant distress and impaired social life and occupation performance (Fekadu, Shibeshi, & Engidawork, 2017).
In the chosen interactive, the patient is a 70-year-old Hispanic American male that reports remarkably diminished interest in engaging in usual activities, states that he has gained 15 pounds in the last two months, and is having trouble sleeping and concentrating at work (Laureate Education, 2019a). The patient has scored a 51 on “Montgomery- Asberg Depression Rating Scale (MADRS),” indicating severe depression (Laureate Education, 2019a). Decision point one the initialization of Zoloft 25mg will be given once daily. After four weeks of therapy, the patient returns for a follow-up visit and reports only a 25% decrease in symptoms and is concerned about the new onset of erectile dysfunction. The decision is made to continue medication at the same dose and counsel the patient. The patient returns for a follow-up appointment and reports that he has stopped medication because of his inability to perform sexually. The third decision was to re-start Zoloft at 50% of the starting dose (12.5mg), to determine whether or not a side effect is dose-dependent. If the side effect of erectile dysfunction returns once the drug is returned to the full dose, you would need to change the drug. Changing to Wellbutrin XL may be appropriate at this point, but may worsen his insomnia. Additionally, guidelines tell us that another SSRI should be attempted for an adequate trial before switching drug classes (Laureate Education, 2019a).NURS 6521 Advanced Pharmacology Discussion
When medications for depression are being prescribed, the provider must consider several factors, including the severity of symptoms, type of depression, duration of therapy, the age of the patient, comorbid conditions, gender, and associated medications (Arcangelo & Peterson, 2017). Serotonin-norepinephrine reuptake inhibitors, such as venlafaxine, duloxetine, and duloxetine, are used as the first-line therapy for depression. They have improved tolerability, reduced lethality in overdose, and the need for few titrations. Age is a significant patient factor that must be considered due to reduced renal and hepatic function, decreased serum albumin, reduced muscle mass, and distribution, metabolism, and excretion of a variety of drugs. Geriatric patients are prescribed one-third to one-half of the usual adult dose (Arcangelo & Peterson, 2017).
Some come side effects include nausea, erectile dysfunction, dry mouth, insomnia, dizziness, drowsiness, and constipation (Anderson et al., 2012). Doses should be started low and slowly increased as tolerated to minimize nausea. The patient or family should understand the goals of the prescribed medications and potential side effects of medication, which may include worsening behavior or suicidal thoughts. If the patient’s condition gets worsens, the patient and family must know the step to take to get in contact with their provider. Educate the patient abruptly stopping the medication can cause withdrawal symptoms, including headache, seizures, nausea, and vomiting. Consulting the healthcare provider is essential when thinking about the discontinuation of the drug (Davis & Lockhart, 2017).
WEEK 9 : Sickle Cell Disease
Hence the name, Sickle Cell Disease causes hemoglobin cells to change from a smooth and malleable disc shape into a rigid sickle shape (National Heart, Lung, and Blood Institute, 2016). This genetic disorder results in a lifetime of anemia and severe painful episodes. hypoxia and/or death of tissue and vital organs. Known as a genetic disorder, SCD affects mainly minority populations such as African Americans, Hispanics, and Middle Easterns.
Therapeutic Management
Pharmacotherapeutics are based on the presenting symptoms of the Sickle Cell disease patient. Symptoms can include pain in chest, extremities, back, and other parts of the body. NSAIDs are used for mild episodes as long as they are not contraindicated. Medications for severe pain are individually based but usually include opioids as first line treatment. Additional supportive interventions such as proper oxygenation, hydration, and maintenance of temperature are necessary. Acute SCD crises are easily exacerbated by stress and introductions of infections in the body. Cultures should be promptly collected to effectively target and treat the offending organism. SC crises may also be treated with a blood transfusion that essentially decreases the percentage of HbS and reducing SCD symptoms (National Heart, Lung, and Blood Institute, 2014). The first new drugs for SCD in 20 years, Endari (L-glutamine oral powder), has been shown to decrease exacerbation’s as well (U. S. Food and Drug Administration, 2017).NURS 6521 Advanced Pharmacology Discussion
Factor: Behavior
Many patients can model behavior that has been proven to decrease the number of exasperation’s. Behaviors such as staying properly hydrated, maintaining normal temperatures, and avoiding areas with low oxygen as well as those in high altitudes have shown to help SCD patients (Centers for Disease Control and Prevention, 2017). Proper health maintenance such as a balanced diet, taking vitamins, not smoking or drinking alcohol, and being up to date on vaccinations can also help decrease symptoms of SCD
References
Centers for Disease Control and Prevention. (2017). Sickle Cell Disease. Retrieved from
https://www.cdc.gov/ncbddd/sicklecell/treatments.html
National Heart, Lung, and Blood Institute. (2014). Evidenced-based management of sickle cell disease: Expert panel report 2014. Retrieved from
https://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines
National Heart, Lung, and Blood Institute. (2016). What is sickle cell disease. Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/sca
U. S. Food and Drug Administration. (2017). FDA approves new treatment for sickle celldisease. Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm566084.htm
U.S. National Library of Medicine. (2017). Sickle cell disease. Retrieved from https://ghr.nlm.nih.gov/condition/sickle-cell-disease#diagnosis
WEEK 10 : Hormone Replacement Therapy -Menopause
Menopause is the permanent cessation of menstrual cycles following the loss of ovarian funicular activity. Although it can occur at any age or gender, said onset usually occurs when a in the age of early 50s (Abernethy, 2015). Some of the multiple symptoms that menopausal patients will report are symptoms such as night sweats, difficulties with sexual pleasure, and difficulty sleeping. A FDA- approved symptom reliever of menopause is Hormone replacement therapy (HRT) that includes estrogen or estrogen with progestin.
Patients to chose to treat menopausal symptoms with HRT reports an increase in quality of life by relieving other symptoms such as mood swings, insomnia, vaginal dryness, erectile dysfunction, and most important, hot flashes. As benefits are reported, so are negative effects such as bone density atrophy and increase risk for blood clots, increased risk for cardiovascular disease, and breast cancer. Due to the detrimental negative risk some chose not to use this therapy and seek other treatments such as supplements and organic/natural products..NURS 6521 Advanced Pharmacology Discussion
The decision to prescribe HRT should be a joint one between the provider and the patient and the patient should be informed of the risks. Patients should also start with the lowest dose possible because the benefits of hormone therapy are dose related (Arcangelo & Peterson, 2013). As the Advanced Nurse Practitioner, I would be sure to complete, and document a meticulous assessment of the patient’s medical history (past, present, and family). I would be sure to advocate for my patients by providing detailed education regarding natural remedies, vitamins, and supplements that aids in management of symptoms and transitions associated with menopause. Education on Monitoring caffeine intake, dietary changes, and routine assessments of changes in the body should also be included. As every patient is unique, Hormone therapy continues to be a valid treatment option for patients who are significantly troubled by menopausal symptoms; however, the risks and benefits of such treatment vary according to age and medical history (Abernethy, 2015).
WEEK 11 : Off-Label Drugs
According to the American Academy of Pediatrics (2014), less than half of medications have specific instructions for children, which leaves the provider to determine the appropriate treatment for the child. The term off-label use, means that the drug is being used for something that was not included in the package insert or approved labeling (Neville, 2014).
Children are not like adults, as their age and weight change rapidly, which can affect dosing of medications, as can body fat, amount of water in a child’s body, plasma, and hormones (Mir, & Geer, 2016). Pharmacokinetics and pharmacodynamics differ in children as well, such as drug absorption and metabolism (Mir, & Geer, 2016). The use of off-label medications in children is done mainly because there are not enough available medications used to treat children (Mir, & Geer, 2016). NURS 6521 Advanced Pharmacology Discussion
There has been recent and on-going concern regarding the use of SSRI antidepressants in children as they may cause a higher incidence of suicide ideation (National Institute of Mental Health [NIMH], n.d.). The Food and Drug Administration (FDA) has issued a black box warning for all SSRI antidepressants, for the potential increase in suicidal thoughts when taken by teens (NIMH, n.d.). Fluoxetine is currently the only SSRI antidepressant that is approved for adolescents ages 8-18 (Drugs.com, 2017). Venlafaxine has also been prescribed to kids, as an off-label treatment, although it has not been approved by the FDA for use in children (NIMH, n.d.). A placebo-controlled study was completed on 766 pediatric patients and the data gathered was not adequate enough to support the use of venlafaxine in children (Drugs.com, 2017). As well as the safety of the drug has not been evaluated beyond treatment longer than six months in children (Drugs.com, 2017). There are many drugs that need further evaluation and research done to clarify the efficacy in children, such as opioids and cardiovascular drugs (Kimland, 2012).
Technology and electronics may play a role in the use of off-label drug use in children in the future. Computerized documentation, which can include measured outcomes, will assist in tracking the use and side effects of off-label drug use in children (Kimland, 2016).
References
American Academy of Pediatrics. (2014). AAP makes recommendation on off-label drugs forchildren. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Makes-Recommendations-On-Use-of-Off-Label-Drugs-for Children.aspx
Drugs.com. (2017). Amoxicillin. Retrieved from https://www.drugs.com/pro/amoxicillin.html NURS 6521 Advanced Pharmacology Discussion