Pharmacology Reasoning Case Study; Susan Jones is a 42- year-old African-American female w, Exams of Nursing

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Pharmacology Reasoning Case Study

Susan Jones, 42-year-old female

Medication Categories Concepts

Antihypertensives Perfusion

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% ✓
• Safety and Infection Control 9 - 15%

Health Promotion and Maintenance 6 - 12% ✓

Psychosocial Integrity 6 - 12% Physiological Integrity

• Basic Care and Comfort 6 - 12%
• Pharmacological and Parenteral Therapies 12 - 18% ✓
• Reduction of Risk Potential 9 - 15% ✓
• Physiological Adaptation 11 - 17% ✓

As the nurse responsible for this patient, you promptly review the medical history and note that she has NKDA. This is her PMH and current home medications documented in the employee’s medical record:

Applying your knowledge of pharmacology, to provide safe patient care, answer the following essential information:

I. Initial Presentation:

Susan Jones is a 42-year-old African-American female with a past medical history of diabetes mellitus type II.

She works in a manufacturing plant in her hometown. While at work, she feels faint and has to sit down. The

occupational nurse is contacted to assess her.

Susan Jones is married and a mother of two elementary age children. She has been employed in her current

position for two years.

1. What data from the present problem 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:

Profile and Medical History

Occupation

Feels faint and had to sit down

Age, race, and medical history can predispose patient to certain health related issues It is abnormal to feel faint and feel the need to sit down while at work

1. 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: Hypertension GERD Type II diabetes mellitus

ASA 81 mg PO daily HTN Lisinopril 40 mg PO daily HTN HCTZ 25 mg PO am HTN Metformin 875 mg PO BID Type^ II^ DM Omeprazole 20 mg PO dailyGERD

2. 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 System Impacted

Common Side Effects

Nursing Assessments:

ASA 81mg NSAID

Salicylate

Treat pain,

fever, and

inflammation

Disrupts prodeuction of

prostaglandins throughout

the body

Cardiovas

cular

Circulatory

Upset

stomach,

heartburn

Monitor for

allergy or

bleeding

Lisinopril 40 mg

ACE

inhibitor

Hyper

tension,

Inhibits angiotensin

converting enzyme which

Cardiovas

cular

Dizziness,

hypotension,

Orthostatic

hypotension,

heart failure dilates vascular smooth Circulatory headache, monitor for

muscle hyperkalemi confusion

HCTZ 25 mg Thiazide

diuretic

Hyper

tension,

heart failure

edema

Inhibits the sodium

chloride co-transporter

system which prevents the

body from absorbing salt

Renal Hypotension

nausea,

electrolyte

imbalance

Monitor for

toxicity and

urinary

retention

Recognizing a potential problem, you collect a full set of vital signs and complete a nursing assessment:

Metformin 875 mg

Anti

diabetic

Diabetes Promotes glucose upstake

by binding to a

glycoprotein receptor

Cardiovas

cular

Endocrine

Nausea,

vomiting

flatulence

Monitor for

hypo

glycemia

Omeprazole 20 mg

PPI GERD

erosive

Inhibits proton pumps

consequently suppressing

Digestive Headache,

abdominal

Monitor for

liver damag

esophagitis gastric acid secretion pain, nausea

Flatulence

pancreatitis

3. Based on this patient’s home medication list, does the nurse need to address the clinical concern of

polypharmacy with the primary care provider?

Patient is using 3 different drugs that act as antihypertensives. This can result in hypotension.

4. 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?

Aspirin, Lisinopril, and hydrochlorothiazide.

II. Present Problem: Susan had an exercise stress test six months ago and was evaluated by a cardiologist. She was referred by her primary care provider due to risk factors of stress, obesity, hypertension, smoking, diabetes mellitus and a positive family history of coronary artery disease. Susan had a negative exercise stress test, but was frightened by the experience. In the past six months, she has stopped smoking, began exercising and lost 20 pounds. She has eliminated many processed foods in her diet and has adopted a "clean eating" approach.

1. What data from the present problem 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:

Risk factors of stress obesity, HTN,

smoking, and DM

Family history of coronary artery disease

Stopped smoking 6 months ago

Lost 20 Lb within 6 months

Began "clean eating" approach

Patient was at high risk for certain medical issues,

especially coronary artery disease

Smoking cessation, weight loss, and "clean eating" can

decrease risk

Current VS: P-Q-R-S-T Pain Assessment:

T: 98.4 F/36.9 C (o) P rovoking/Palliative: Reports no pain at this time

P: 90 (reg) Q uality:

R: 15 (reg) R egion/Radiation:

BP: 100/70 S everity:

O2 sat: 99% room air T iming:

Blood Glucose finger stick: 101

2. 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 100/70 Patient has histor of HTN

All other VS are normal Blood pressure is low

Blood glucose within a May be related to feeling faint and feeling the need to sit down

normal range

No pain

Current Assessment: GENERAL SURVEY: Pleasant, in no acute distress, calm, body relaxed, no grimacing, sitting in chair NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30 - 45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants GU: Reports no changes in urinary habits. Urine reported as clear, non-odorous, not painful, no burning, frequency of urination INTEGUMENTARY: Skin warm, but diaphoretic, normal color for ethnicity. No clubbing of nails, cap refill < seconds. Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.

3. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?

(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Assessment Data: Clinical Significance:

Normal assessment findings

Diaphoretic

Diaphoresis, or excessive sweating, can cause a loss of body

fluid and can lead to low blood pressure

4. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify

the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX Management of Care/Physiologic

Adaptation)

Likely Problems: Additional Clinical Data Needed:

Hypotension

Impaired fluid imbalance

Medication reconcilliation

Intake and output

Remeasure blood pressure

There has been no change in Susan’s status. She currently denies feeling lightheaded. Her husband arrives, and transports her to her primary care provider’s clinic.

S ituation:

Name/age: Susan Jones; 42 y/o

BRIEF summary of primary problem: Feeling faint, low blood pressure, diaphoretic

B ackground:

RELEVANT past medical history: DM type II, HTN, FMH - coronary artery disease

RELEVANT background data: Last 6 months, stopped smoking, lost 20 Lb, and altered diet

A ssessment:

Most recent vital signs: T: 98.4 F

P: 90

RELEVANT body system nursing assessment data: R:

RELEVANT lab values:

BP: 100/

O2 sat: 99% RA

Patient response: Blood^ glucose:^101

INTERPRETATION of current clinical status (stable/unstable/worsening): Normal assessment^ findings

Patient is diaphoretic

R ecommendation: Suggestions to advance the plan of care: (^) Diagnostic tests for perfusion, treat patient for hypotension and fluid imbalance

The Primary Care Provider Orders the Following:

5. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)

Orders: Rationale: Expected Outcome:

Complete blood count (CBC)

Basic metabolic profile (BMP)

Diagnostic test are to provide information

regarding circulation, perfusion, and

electrolyte/fluid imbalances

Patient data will be

indicative of patient

condition

Hgb A1c

Urine analysis (UA)

Urine hCG

12 lead EKG

Recognizing that a problem is present, use SBAR to concisely communicate your concern to the primary care provider:

Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 7.0 13.1 250 55 0 Most Recent: 8.5 12.8 225 65 0

Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 135 3.4 105 0. Most Recent: 137 3.7 117 0.

Urinalysis + UA Micro Color: Clarity: Sp. Gr. Protein Nitrite LET RBCs WBCs Bacteria Epithelial Current: dark yellow

clear 1.025 neg neg neg neg neg neg neg

Misc. Hgb A1c Urine hCG Current: 6.4 Neg Most Recent: 6.6 n/a

6. What lab results are RELEVANT and must be NOTICED as clinically significant by the nurse?

(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Diagnostic Data:

Clinical Significance: TREND:

Improve/Worsening/Stable:

Na+ is slightly low Indicative of hyponatremia, related to "too much"

water in the body.

Improving

Urine color is

dark yellow Urine is not being dilluted properly

Stable

Worsening

Hgb A1c is high Indicative of diabetes

III. Put it All Together to THINK Like a Nurse!

1. Interpreting all clinical data collected, what is the priority problem? What is the pathophysiology of the

priority problem? (NCLEX Management of Care/Physiologic Adaptation)

Priority Problem: Pathophysiology of Problem in OWN Words:

Hypotension

related to fluid

imbalance

Patient is experiencing fluid imbalance related to an issue with perfusion as

shown by hypotension, dark yellow urine, and diaphoresis.

12 Lead EKG is normal sinus rhythm-rate 72. The following diagnostic test results just posted in the electronic health record:

Her primary care provider decreased her BP medications to Lisinopril 20 mg and HCTZ to 12.5mg. She is scheduled for a follow up visit in two weeks.

Susan Jones follows up in the clinic two weeks later. She has been taking all medications as ordered. She denies any recurrent episodes of lightheadedness and has brought her BP log with her.

2. What nursing priority (ies) and goal will guide how the nurse RESPONDS to formulate a plan of care?

(NCSBN: Step 4: Generate solutions/Step 5: Take action/NCLEX Management of Care)

Nursing PRIORITY: Decreased cardiac output related to fluid imbalance and history of hypertension as evidenced by hypotension, diaphoresis, anf feeling of faintness

GOAL of Care: Patient will demonstrate adequate cardiac output as evidenced by blood pressure and warm, dry skin.

Nursing Interventions: Rationale: Expected Outcome:

Assess heart rate and blood in order to monitory response to treatment Patient data will

provide data inorder to plan out baseline care Patient intake and out put will be normal and not indicative of poor perfusion or fluid imbalance. Patient will have a better understanding of medications as well as condition

pressure since reduced cardiac output results in

Monitor intake and output reduced perfusion of the kidneys, with a

Examine laboratory data resulting decrease in urine output

Assess blood pressure prior to As lab datam may be indicative of condition

administration of medication Since certain medications can lower blood

Teach patient to monitor for signs pressure

of decreased cardiac output In order to monitor patient status

Evaluation: Two Weeks Later…

1. After implementing the plan of care, EVALUATE by INTERPRETING relevant clinical data to determine if patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Assessment Finding: Improving: Declining: No Change: Denies recurrent episodes of lightheadedness Systolic BPs the last week have been between 114 - 130 Diastolic BPs the last week have been between 72 - 80 Current BP in clinic: 134/ Heart rate: 76 (reg) 2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved, what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Overall Status: Additional Interventions to Implement: Expected Outcome: Patient status has improved, as shown by increased blood pressure and denial of reccurent episodes of lightheadedness

Teach patient to assess blood pressure prior to

administration of medication

Teach patient to monitor for signs of decreased

cardiac output

Patient will have a better

understanding of

medications as well as

condition

3. To develop clinical judgment, reflect on your thinking by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify?

Identifying patient data outside of normal or

healthy range

Relating learning concepts to situations

presented in case studies

Finding appropriate nursing inrventions within my

scope of practice that also help the patient.

What did you learn? How will you apply learning caring for future patients?

How perfusion, cardiac output, blood pressure

and fluid imbalance relate to one another

Looking at medications, how they interact with

eachother, and the baseline information that needs to

collected prior to administration

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