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Case Study: Mrs A is a 71 year old widow with CCF and osteoarthritis who has recently been exhibiting quite unusual behaviour. Her daughter is concerned about her mother's ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a depending illness. Over the last two to three months Mrs A has become confused, easily fatigued and very irritable.
She has developed disturbing obsessive / compulsive behaviour constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly mould. Her prescribed medications are: Frusemide 40 mg daily in the morning Digoxin 250 micrograms daily Paracetamol 500 mg, 1 - 2 tablets 4 -hourly PRN Piroxicam 20 mg at night Mylanta suspension, 20 ml PRN Colony 120 mg, 1 - 2 tablets at night Critically discuss this case study in terms of the problematic nature of this patient's pharmacological management. Your answer should include a discussion of the problems of poly pharmacy as it is related to this case study and the assessment / management and educational strategies which could have been implemented to improve the outcome of Mrs A.
Introduction In analyzing the case study of Mrs A, a number of factors come into play. The patient has recently been exhibiting unusual symptoms including confusion, fatigue, irritability and apparent obsessive / compulsive behaviour. Her daughter fears the onset of a depending illness. However, upon close examination of Mrs A's prescribed medications, very different conclusions can be drawn.
Overview of each Mrs A's medical conditions The Online Medical Dictionary at web defines CCF as a condition where there is ineffective pumping of the heart leading to fluid retention and organ congestion. The site defines osteoarthritis as "Noninflammatory degenerative joint disease occurring chiefly in older persons. " There are various drug treatments available for these conditions. Poly pharmacy and Mrs A's problematic pharmacological management A close examination of Mrs A's drugs, serves to reveal the problematic nature of her pharmacological management and the results of poly pharmacy. Frusemide 40 mg daily in the morning Loeb, S (2001: 649) includes the following factors in his outline of furosemide.
Indications & amp; dosage: Hypertension - adults 40 mg P. O. b. i. d. Adjust dose according to response.
Adverse reactions: Hypokalemia (low potassium), fluid and electrolyte imbalances. Relevant interactions: Care should be exercised in patients receiving potassium depleting agents. Nursing considerations: Monitor serum potassium level. Watch for signs of hypokalemia (for example fatigue, muscle weakness and cramps).
Give P. O. and I. M. preparations in a. m.
to prevent nocturnal. Applications to case study It is likely that furosemide is being given to Mrs A as diuretic therapy to treat fluid retention typically associated with Congestive Cardiac Failure. Mrs A's dose of 40 mg daily in the morning is a standard initial dose however it should be adjusted according to response. Morning dose is correctly implemented to alleviate sleeplessness and reduce gastric disturbance. Frusemide could be increasing Mrs A's sensitivity to digoxin.
As such, an alternate drug such as Zantac may be advisable. Moreover, a high potassium diet may help reduce potassium loss and the risk of hypokalaemia whilst eliminating the need for potassium supplements. Mrs A needs to be monitored for symptoms of hypokalaemia and her serum potassium levels checked. Digoxin 250 micrograms daily McKenry, L & amp; Salerno, E (1989: 454 - 458) includes the following factors in their outline of digoxin.
Indications & amp; dosage: In elderly patients, an initial dose of 500 to 750 micrograms may be given as a single dose. Maintenance dose for adults over 65 years is 125 micrograms P. O. daily and for frail or underweight elderly patients this may be only 63 micrograms daily or 125 micrograms every other day. Adverse reactions: Fatigue, muscle weakness, agitation, yellow-green visual disturbance, gastric irritation, arrhythmias.
Relevant interactions: Diuretics - hypokalemia, predisposing patient to digitalis toxicity. Antacids - decreased absorption of oral digoxin. Nursing considerations: Obtain baseline data (heart rate and rhythm, blood pressure, and electrolytes) before giving first dose. Dose is adjusted to patient's clinical condition and is monitored by serum levels of cardiac glycoside, calcium, potassium, magnesium, and by ECG. Check for symptoms of toxicity. Applications to case study Digoxin is being used to treat Mrs A's CCF.
The dose of 250 micrograms daily far exceeds the regular maintenance dose for a patient of her age. It is thus almost certain that Mrs A is suffering from digoxin toxicity which is most likely being compounded by taking furosemide. Mrs A's symptoms of confusion, fatigue, irritability and visual disturbance are symptomatic of digoxin poisoning. Mylanta (also being taken by the patient) can suppress the effectiveness of digoxin however in this case the digoxin dose is so high that Mylanta would be having a minimal impact. Mrs A's digoxin dose must be adjusted to her clinical condition and her serum levels monitored.
Digoxin should be taken with meals to decrease the effects of gastric irritation that can accompany treatment. Frusemide and digoxin can both cause hypokalemia; this can be controlled by encouraging Mrs A to eat potassium-rich foods, instructing her about dosage regimen, reportable signs of digitalis toxicity, and follow up plans. Paracetamol 500 mg, 1 - 2 tablets 4 -hourly PRN Local, S et al (1994: 813 - 815) includes the following factors in their outline of paracetamol. Indications & amp; dosage: Adults and children over 11 years - 325 mg to 650 mg P. O. q 4 hours; or 1 g P.
O. q. i. d. p. r.
n. Maximum dosage should not exceed 4 g daily. Dosage for long term therapy should not exceed 2. 6 g daily. Adverse reactions: severe liver damage with toxic doses, rash.
Relevant interactions: None. Nursing considerations: Has no significant anti-inflammatory effect. Warn patient that high doses can cause hepatic damage. Applications to case study It is possible that paracetamol is being given to Mrs A to treat the pain associated with her osteoarthritis, or for headache which may be a side effect of piroxicam administration.
The dose being taken is relatively high. Paracetamol does not react adversely with the other drugs being taken by Mrs A, however her dose must be monitored and adjusted according to need. The nurse needs to assess why Mrs A is taking paracetamol and whether it is beneficial. Piroxicam 20 mg at night Brody, T et al (1994: 397) includes the following factors in his outline of piroxicam.
Indications & amp; dosage: 20 mg P. O. once daily. If desired, the dose may be divided. Adverse reactions: Headache, drowsiness, nausea, epi gastric distress, peptic ulcerate...
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