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

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42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

Pharmacology Reasoning Case Study

Susan Jones, 42-year-old female

Medication Categories Concepts

Antihypertensives Perfusion

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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%^ ✓

I. Initial Presentation:

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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: Client has dx of diabetes mellitus type 2

At work client feels faint, dizzy, and has to sit down

This dx typically comes with many complications, perhaps hypoglycemia could be contributing to her reason for admission

This client could be dehydrated, maybe she is not getting enough O2, or could be related to her diabetes. Need to assess the client further investigation of CV system indicated.

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:

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 ASA 81 mg PO daily GERD Lisinopril 40 mg PO daily Type II diabetes mellitus HCTZ 25 mg PO am Metformin 875 mg PO BID Omeprazole 20 mg PO daily

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

2. List each home medication from the scenario and answer the following: (NCLEX Pharmacologic and Parenteral

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

Therapies) Home Medication:

Pharm. Class: Indication(s): Mechanism of Action In OWN WORDS:

Body System Impacted

Common Side Effects

Nursing Assessments:

ASA 81mg NSAID Antipyretic Salicylate

Anticoagulant/Blood Thinner

Decreases the chance of occlusion in blood vessels by platelet aggregation

CV Bleeding, hemmorage, nausea, bruising

Watch for

hypersensitivity

reactions.

Assess for

salicylate

Lisinopril 40 mg (^) ACE inhibitor

HTN Renal Hypotension, dizziness

Monitor BP frequently, I&O, weights, elytes. Test pt for

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

pregnancy. HCTZ 25 mg Thiazide diuretic

HTN A loop diuretic that increases the output of urine

CV,

Renal

Electrlyte imbalance, dehydration

Monitor BP frequently, I&O, weights, elytes

Metformin 875 mg (^) Biguniade Antihyperglycemic agent

Diabetes and Prediabetes

Inhibits glucose production and release from the liver

Endocrine

N/V/D – GI

upset

Monitor glucose, HbA1C, metabolics

Omeprazole 20 mg

Anti ulcer agent Proton pump inhibitor

Tx GERD or acid reflux

Binds to gastric enzymes preventing reflux of HCL and diminished accumulation

GI Tract GI upset/mild discomfot

Assess for stomach pain, bleeding, or other complications. Advise pt not to over-take as could lead to alkalosis

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?

No, due to the patients current dx the medications are appropriate.

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?

No, I don’t see a need to contact provider

II. Present Problem:

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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: Taking multiple antihypertensives Taking metformin Obese but losing weight – 20 lbs

Could lower BP to dangerous levels, put pt at risk for falls Pt is diabetic increasing need for individualized treatment D/t pts obesity status losing weight is healthy and can help improve patients quality of life and help symptoms of other complications

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

Stress Test Taking multiple diuretics

Negative – CV not a big worry at this point Would want to monitor kidney fxn regularly as well as electrolyte levels for imbalances

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

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: Pulse – 90 BP – 100/ Blood Glucose - 101

WNL but on the higher side – would want to watch Low BP could indicate the need for medication change – too low BP put pt at risk for falls Normal blood glucose shows pts symptoms are likely not due to hypoglycemia

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.

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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:

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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:

Syncope r/t hypotensive status Medications likely need adjusting

Patient needs labs, BUN, Creatinine, Electrolytes, GFR, and preganancy test.

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

S ituation:

Name/age: Susan Jones, 42 year old female

BRIEF summary of primary problem: Pt presented with feelings of faintness and dizziness.

B ackground:

RELEVANT past medical history: Hx of diabetes melitus type 2, HTN, family hx of CAD

RELEVANT background data: Recently stopped smoking, lost 20 lbs, blood glucose stable

Likely due to the combo of medications Could be body/heart working harded to pump low blood volume Cause is unknown perhaps pt is uncomfortable or anxious – warrants further investigation

Low BP Elevated Pulse Diaphoretic

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

A ssessment:

Most recent vital signs: Pulse:90, BP:100/70 ,T: 98.4 F/36.9 C (o), R: 15 (reg), O2 sat: 99% room air and

Blood Glucose finger stick: 101

RELEVANT body system nursing assessment data: Patient no longer feels faint after sitting, diaphoresis

RELEVANT lab values: Blood glucose: 101

Patient response: Patient is feeling better.

INTERPRETATION of current clinical status (stable/unstable/worsening): Appears stable

R ecommendation:

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

Suggestions to advance the plan of care: Contact health care provider for the pregnancy test and other recommended labs.

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.

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)

Hgb A1c

Urine analysis (UA)

• Assesses RBC count, as well as WBC for

signs of infection.

• Fluid balance, electrolyte balance, kidney

functioning.

• assess the blood glucose over a period of

3months

• assess the kidney function.

Pt. will not have an

infection.

• Pt. will have values

withing normal limits

• <6.5%
• No infection
• negative

Urine hCG

• Pregancy indicator 12 lead EKG
• Assessing pt. for dyshythmia

12 Lead EKG is normal sinus rhythm-rate 72.

The following diagnostic test results just posted in the electronic health record:

Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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:

WBC neg for No^ systemic^ infection^ or^ urine^ infection

Patient is not losing too much electrolytes w/ current meds

Normal levels, kids are adequately clearing meds

Stable

Bacteria

Na+ 135, K+ 3.4 Stable

Creat 0.

Stable

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:

Patient feeling faint/dizzy & syncopal episode

Patient incorporated many healthy lifestyle improvements losing weight quitting smoking and changing eating habits, syncopal episode most likely d/t blood pressure medication excess and lack of consistent monitoring of BP

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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: Patients^ safety^ is^ priority^ -^ Especially

Preventing falls

GOAL of Care: Patient^ will^ have^ normal^ BP^ and^ not^ experience

anymore syncopal episodes

Nursing Interventions: Rationale: Expected Outcome:

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

• Pt. education on how to monitor BP at home – would rec keeping journal of BPs

Keep track of BP to monitor for changes to present to doctor if worsening & safe drug administration

Prevent falls and syncopal episodes

Patient will keep record and have bp WNL

• Teach patient about ortho hypotension and how to change positions slowly

Patient will not expernce any more syncopal episodes

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.

Evaluation: Two Weeks Later…

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.

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 X

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

Systolic BPs the last week have been between 114 - 130 X Diastolic BPs the last week have been between 72 - 80 X Current BP in clinic: 134/82 X Heart rate: 76 (reg) X

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 seems stable

None needed at this time Patient will maintain positive outcome and continue positive healthy lifestyle changes

42-year-old African-American female with a past

medical history of diabetes mellitus type II.ALL

ANSWERS 100% CORRECT FALL-2021 SOLUTION

AID GRADE A+

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?

I did well interpreting the relevant data and its clinical signifigance

I haven’t taken pharmacology yet so I don’t know much about a lot of the medications and their side effects and what to watch out for.

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

I learned how symptoms combined with the admitting dx can be more than what they initially may seem – further investigation is a good thing!

I will always investigate the symptoms, data, assessments, and history continually and often to find the best outcomes and provide optimal care.