March 14, 2011
Pharmacology
Dr. Hutcherson

PROJECT FOR NON-CLINICAL PHARMACOLOGY STUDENT
BY SUZANNE NATION

PART 1: THE PATIENT’S MEDICATIONS

1. INTRODUCTION a. Mrs. Jenkins is a 73 year old Caucasian widow who lives alone and is a retired school teacher of 35 years. She is fiercely independent but is looked after by oldest daughter who comes every few days to take her to appointments and shopping for groceries. Being a former school teacher Mrs. Jenkins is well educated and knows a good deal about her medical condition and medications. She always tries to follow a strict diabetic diet and take her medications exactly as prescribed, however, when her daughter stops by to see her she is shocked to find her mother confused and having difficulty breathing. She immediately calls 911 and Mrs. Jenkins is brought to the hospital. The emergency room doctor is informed of her medical history that includes insulin dependent diabetes, congestive heart failure, hypertension, osteoarthritis, and chronic obstructive pulmonary disease. Further diagnostic testing reveals Mrs. Jenkins has pneumonia and needs to be admitted for antibiotic treatment. b. Primary diagnosis is pneumonia which is an infection of the lungs caused by bacteria, virus, and sometimes fungus, characterized by inflammation of the lungs, congestion, shortness of breath, cough and fever. Symptoms may vary.
Secondary diagnoses
COPD Chronic obstructive pulmonary disease which is a combination of chronic bronchitis and emphysema in the lungs that allow the lungs to become narrow and inflamed. The result is shortness that progressively worsens over time. Mrs. Jenkins’ COPD is exacerbated by her pneumonia infection.
CHF Congested heart failure is chacterized by the inability of the heart to effectively pump blood throughout the body.
Hypertension which is when the systemic arterial blood is chronically elevated usually above 140/90.
Osteoarthritis is a degenerative joint disease where cartilage wears down over time between joints leaving bone rubbing bone with movement causing severe pain.
Insulin dependent diabetes is where there is an insufficient amount of insulin produced by the body or the body has a resistance to it and cant effectively use glucose as a result.
Constipation is an inability to defecate due to hardening of stools from lack of water in the large intestine.

2. HOME MEDICATIONS
a. 1. Motrin 200mg by mouth every 6 hours 0600,1200, 1800, 2400 for pain related to osteoarthritis 2. Metamucil 1 tsp / glass of juice each 0600 for constipation due to diuretic use
3. Centrum multivitamin once a day at 0800am with breakfast because she feels like she doesn’t eat enough vegetables or enough iron.
4. Oxygen 2 liters / min via nasal canal for overexertion and shortness of breath.
5. NPH insulin 25 units subcutaneous in the fat of her abdomen and rotates to outer thighs every other day (before breakfast at 0700am) for her insulin dependent diabetes
6. Lanoxin .125mg by mouth daily at 0700am for congestive heart failure
7. Lasix 40mg by mouth daily at 0700am for swelling in her legs due to congestive heart failure.
8. Lopressor 50mg, daily by mouth at 0700am for high blood pressure (hypertension)
9. K-Dur 20meq, one by mouth daily at 0700am for potassium replacement because of the diuretic
10. Prednisone 10mg, one by mouth at 0700am for chronic obstructive pulmonary disease to help her breathe.
11. Alupent inhaler, 2 puff by mouth via spacer four times a day.
12. Proventil inhaler, 2 puff by mouth via spacer four times a day at 0800, 1200, 1700
b. 1. NPH insulin 25 units subcutaneous daily in AM. Pt is insulin dependent diabetic meaning her body either has a resistance to insulin or a deficiency in the amount a insulin that is produced . It’s use is to supplement the insulin the body produces to enable effective use of glucose
2. Lanoxin 0.125mg by mouth once a day is indicated in this patient’s case for CHF (congestive heart failure) to slow and strengthen her heart beat (positive inotropic effect). Also promotes tissue perfusion and diuresis as a result of improved circulation and improves coronary circulation.
3. Lasix 40mg one by mouth once daily for CHF to eliminate excess fluid buildup in body tissues to decease work load of the heart. Also this type of diuretic is not a potassium sparing diuretic so, often potassium replacement is needed, which leads us to our next drug.

4. K-dur 20meq by mouth once a day. It’s given to replace potassium lost form taking Lasix, a non potassium sparing diuretic. If potassium levels are too low the patient can suffer serious cardiac dysrhythmia.
5. Lopressor 50mg one by mouth daily for hypertension is a beta blocker that reduces the workload and helps the heart beat more regularly.
6. Prednisone 10mg one tablet by mouth every morning is given to reduce swelling in bronchioles and is a corticosteroid used to treat COPD (chronic obstructive pulmonary disease).
7. Alupent inhaler, 2 puffs 4 times a day is a beta adrenergic receptor agonist that simulates bronchodilation . Used to treat COPD
8. Proventil inhaler, 2 puffs 4 times a day, is used to treat COPD works as a bronchodialator and prevents bronchospasms .
9. Motrin 200mg, one tablet by mouth 4 times a day is an anti-inflammatory nsaid used for mild pain due to osteoarthritis, works by decreasing swelling and stiffness of joints.
10. Metamucil 1 tsp / glass of juice every morning to prevent constipation likely caused by fluid depletion from diuretic use. Metamucil is a dietary fiber that draws fluid to gastrointestinal tract to aid with the elimination of wastes.
11. Centrum multivitamin, one by mouth daily for replenishment of vitamins lost with use of a diuretic.

2. HOME MEDICATIONS
c. Mrs. Jenkins is unable to recall the last time she checked her blood sugar or took her medications. She states that she has not felt well for several days and did not want to bother her daughter. Mrs Jenkins is usually compliant with all her medications and realizes the importance of taking them, however, her daughter noticed that the medications in her weekly pill organizer were still there for the past few days. Based on the patient’s assessment on admission along with laboratory values of bloodwork would indicate her medications were not taken most likely due to her confused state caused by low blood oxygen levels and deteriorating condition as a result of pneumonia infection.
Vital signs on admission were
Temp 101.8

Pulse 104
Resp. 28
B/P 168/94
Vital signs indicate Lanoxin, Lopressor, and oxygen probably not taken or used and temperature indicative of an infective process.
Lab values
CBC
Hg 10.2
Hct 34
WBC 18,000
Due to increased WBC count along with elevated temp. indicates an infection in her body
ABGs
Ph 7.38
Po2 65
Pco2 68
Hco3 28 on room air
Arterial blood gases indicate Mrs. Jenkins has an acid –base disorder most likely respiratory acidosis meaning there is a build- up of carbon dioxide in the blood caused by hypoventilation.
Chemistry panel
Glucose 234
Na 142
K 3.2
Bun 24
Creatinine 1.6
Indicates insulin probably not taken nor K-DUR or Lasix 3. Medications During Hospitalization
a. NPH insulin 25 units subcutaneous injection every morning at 0700 continued while in the hospital because dosage continues to control diabetes
Lanoxin 0.125mg one tablet daily was increased to Lanoxin 0.25mg once a day at 0800 by mouth because serum digoxin levels were too low probably because patient missed doses
Lasix 40 mg one tablet by mouth every morning was not continued because patient was admitted with dehydration
Lopressor 50 mg by mouth once every morning was continued because still needed her hypertension controlled
K-DUR 20meq one tablet by mouth every day at 0800 was not ordered while in the hospital because it was ordered to be given in her IV fluids
Prednisone 10 mg one by mouth daily at 0800 am was continued while in the hospital because it helps to control swelling in the lungs from her COPD
Alupent inhaler 2 puffs four times a day and Proventil inhaler 2 puffs four times a day was not continued while in the hospital because Albuterol nebulizer aerosol treatments were ordered because they are a more effective means of medication administration especially for treatment of pneumonia when patient has increased difficulty breathing
O2 at 2L/min via nasal canula was not continued as PRN but as continuous treatment due to low oxygen saturation levels, secondary to pneumonia diagnosis
Motrin 200mg one by mouth four times a day was not continued because Tylenol 325mg 2 tablets every 4-6 hrs. as needed for fever or pain because Tylenol is more widely used in hospitals due to the sensitivity of some patients with Motrin especially G.I. symptoms in patients with fever.
Metamucil 1tsp/ glass juice each morning for constipation was not continued because Laxative of choice was ordered instead because fiber interferes with digoxin absorption. The patient also has more options for choosing a laxative when one is needed and not scheduled daily when nutrition level is compromised and laxative may not be needed at this time.
Centrum multivitamin one by mouth daily was not continued because patient is able to eat adequately and extra vitamins are not necessary.
b. New Medications ordered while patient in the hospital.

IV fluids of Normal Saline with 40meq of KCL infused at 125ml/hr was ordered to rehydrate patient and bring potassium level to normal range. Infusion of potassium is quicker than taking orally.
Enalapril 2.5mg one by mouth daily to help keep blood pressure under control along with Lopressor.
Sliding scale insulin coverage with regular insulin ordered for accucheck insulin coverage
<200------none
201-300------4 units
301-400------8 units
>400 call MD
Rocephin 1 gram IVPB four times a day at 0600,1200,1800,2400 for pneumonia infection
Ambien 5 mg one by mouth at hs as needed for sleep because it is often difficult to sleep in the hospital and rest is important in recovering.
4. Discharge Medications
a. In comparison to the home medications the inpatient medications were mostly the same with the addition of aerosol nebulizer treatments, an antibiotic, and continuous oxygen. These medications were added because of the diagnosis of pneumonia. Upon discharge of this patient I anticipate all the same home medications with the addition of Enalapril 2.5 mg one daily the doctor added for hypertension and a course of an antibiotic possibly Augmentin if there is no allergy to penicillin
b. Low potassium levels can potentially increase the risk for digoxin toxicity so maintaining a normal potassium level of 3.5 – 5.0 meq/L by taking supplements is of major importance and should be stressed to patient to reduce the risk. Also the need to stress the importance of not missing a dose of Prednisone and because steroids can increase blood glucose, monitoring glucose frequently is important.
5. Patient Education Before patient teaching can begin always assess the patient’s level of knowledge regarding their diagnosis and medication regime. Patient education should include listing all medications to be continued at home as prescribed by the physician along with emphasis on keeping all follow up appointments. Inform patient of signs and symptoms to be aware of such as fever increased shortness of breath, weakness, nausea and vomiting, vision disturbances such as green yellow flickering lights which could indicate digoxin toxicity. Advise patient to seek medical treatment should any complications arise. Part II: In- depth Analysis of a Medication
1. Drug/ Identification
Digoxin ( Lanoxin ) is a cardiac glycoside
2. Use/Action
Indicated for the treatment of heart failure and atrial fibrillation. In this case it was prescribed for CHF in which case the heart is weakened and is ineffective in pumping blood throughout the body. The body becomes overloaded with fluid as the ventricles become stiff and can’t fill properly between beats. As the ventricles become stretched blood and fluid begins to backup and congest the liver, lungs,abdomen and lower extremities as evidenced by Mrs.Jenkins shortness of breath and 3+ pedal edema.
Digoxin is a positive inotropic drug that increases the force and velocity of the heartbeat without any increased demands on oxygen. Making the heartbeat stronger can increase profusion of tissue and decrease the buildup of fluid in the lungs and tissues greatly improving the patient’s condition.
3. Dose
Usual adult dose is 0.125mg/day to 0.5mg/day by mouth. Mrs. Jenkins dose was increased from 0.125mg/day to 0.5mg/day possibly due to the deteriorating condition of her heart.
4. Pharmacokinetics
Digoxin is absorbed in the gastrointestinal tract and metabolized in the liver from there it is distributed throughout the body in blood and tissues and is excreted through the kidneys. Mrs. Jenkins use of fiber is contraindicated with digoxin treatment because fiber inhibits its absorption. Patient also needs to be cautioned against the use of herbal supplements such as Ginseng that may increase digoxin levels.
5. Adverse Factors
There are no major side effects associated with Digoxin, just diarrhea and nausea in some cases.
Toxic effects may include symptoms such as anorexia, nausea, vomiting, visual disturbances such as blurred or yellow vision, headache, weakness and dizziness.
6. Nursing implications
a. Assessments important to the plan of care include monitoring vital signs especially heart rate and blood pressure. Lung sounds for crackles or rales and extremities for signs of edema that reflect therapeutic effects of drug therapy. Lab values include serum digoxin levels to ensure therapeutic range and electrolyte levels especially potassium levels because if it is too low can cause potential for digoxin toxicity. Also urinalysis to monitor renal function because impaired renal functioning is major concern for digoxin toxicity since the kidneys are the main site of excretion. Expected lab values for normal digoxin levels are 0.5 to 2 ng/Ml if any higher toxicity is suspected. Potassium levels should be between 3.5-5.0 meq/ L, if lower inquire with patient about their medication compliance and possibly consult with physician.
b. Dose should be scheduled once a day in the morning. Pulse rate should be checked prior to administration and if less than 60 beats per minute dose should be held and physician notified.
c. Patient education should include taking as prescribed by doctor and checking heart rate prior to taking and if less than 60 beats per minute to hold dose and contact physician. Inform patient to limit amount of dietary fiber because it inhibits absorption in large amounts. Also avoid ginseng, hawthorn, and St.John’s wart supplements that could interfere with digoxin absorption. Digoxin medication should always be stored in original bottle to avoid confusion and kept out of reach of children. Patient should be aware of signs and symptoms of toxicity that include visual disturbances, blurred or yellow vision, headache, weakness, nausea and vomiting and should contact medical provider should there be concerns.

REFERENCES
Lilley, Rainforth Collins, Harrington, Snyder ( 2011 ) (Chapter 22) Heart Failure Drugs , Pharmacology and the Nursing Process ( sixth edition ) Mosby, Inc., an affiliate of Elsevier Inc.

Glaxo Wellcome Inc. (Feb. 1995) Lanoxin, retrieved March 14, 2011 from http:// www.druginfonet.com/Lanoxin

RnCeus Interactive, LLC. (2005) Simple Method of Acid – Base Balance Interpretation, retrieved March 14, 2011 http://www.rnceus.com/abgs/abgmethod.html

GlobalRPh Inc., (1993-2011) The Clinician’s Ultimate Reference Retrieved March 14, 2011 http://www.globalrph.com/labs.html