Ques 1. What is Neostigmine? Discuss why this drug may have been given to Mrs. Lim. Include drug action and desired effects, adverse drug reaction(s), drug interactions, appropriate dosage and rationale for use.

Ans 1. Neostigmine is a drug which belongs to the family of medicines called as the anticholinesterases (neostigmine). This drug works by inhibiting the action of the enzyme acetylcholinesterase, which in turn leads to a prolonged action of the enzyme acetylcholine. Acetylcholine stimulates the muscarinic receptors present in the muscles, thus causing muscle contraction.

Vecuronium, given to Mrs. Lim is a neuromuscular blocking agent. To subside its effect, she was given Neostigmine, which also improves the respiratory function (Brodie & Axelrod, 2009). Neostigmine produces an antagonistic effect to Vecuronium.

After Vercuronium, a dose of 2.5mg or 5mg Neostigmine is sufficient to produce a muscle twitch of about 90%. It also leads to increased cardiovascular effect (Caldwell,J., 1995). The drug is required to cause muscle contraction opposite to the muscle relaxation, as was caused by the dose of anaesthesia.

Some of the common side effects associated with the drug use are nausea, vomiting, diarrhoea, stomach cramps, involuntary urination, faintness, muscle cramps or twitching. These symptoms however, due not require any medical treatment. Some other severe problems associated with this drug are slow heart rate, shortness of breath, severe rashes, irritation, swollen face , convulsions, etc. these however, require immediate medical attention.

After Vercuronium, a dose of 1.25mg of Neostigmine is very ineffective. A minimum dose of 2.5mg or 5mg is required to produce the desired effect. Neostigmine should not be used in case of Asthma, Epilepsy, Low blood pressure, Parkinson’s disease, Peptic ulcers, People with recent heart attacks, etc.

Ques 2. Why Mrs. Lim is prescribed Amiodarone? Discuss the rational behind the use of Amiodarone therapy for Mrs. Lim.

Include in your discussion, action therapeutic benefits of the drug for Mrs. Lim, as well as possible adverse and/ or side effects and nursing precautions that should be considered when administering Amiodarone.

Ans 2. Amiodarone is an antiarrythmic medication which is used to correct the abnormal heart beats (amiodarone, cordarone). Amiodarone interacts with the beta blockers, like atenolol, propranolol, metoprolol, etc. resulting in slow rate of heart beats.

In case of Mrs.Lim, she suffers from Atrial Fibrillation. This is the most common type of arrhythmia seen in clinical practice (Hirohata et al., 2011, pp.276-283).To deal with this, doses of Amiodarone are prescribed, which help in correcting the rate of heart beat.

Some of the common side effects associated with the drug Amiodarone are sweeling on the face, difficulty in breathing, chest pain, coughing, etc. Serious sde effects associated with the drug includes lethal interstitial pneumonitis (Jahangir et al., 2007, pp.3050-6).

Before taking in Amiodarone, one should always tell the doctor if he/ she is allergic to iodine or any other substance. There are certain sensitive conditions which need to be told to the physician before taking in Amiodarone. These are as follows:

← Liver disease

← Lung disease

← Thyroid problem

← Pregnancy

← breast feeding

As this drug makes one dizzy, it should not be combined with driving, use of any kind of machinery, etc. Moreover, alcoholic beverages should be avoided with dosages of Amiodarone. This drug may interact with some other drugs that a person may be consuming, like beta blockers, calcium channel blockers, etc(Singh, Connolly& Crijns, 2007, pp.987-99). Hence, a practitioner should always be consulted before taking in this drug.

Ques 3. Lanoxin was previously a preferred medication in the treatment of Atrial Fibrillation. Explain why Lanoxin was useful in the treatment of Atrial Fibrillation. Why is it no longer the first line treatment for Atrial Fibrillation?

Lanoxin is a drug which belongs to the class of drugs known as the cardiac glycosides. This was mainly used for Atrial Fibrillation and Congestive Heart failure. Lanoxin increases the strength and vigour of heart contractions. It increases the force of contraction of the muscle by inhibiting the activity of the enzyme ATPase, which controls the activity of sodium, calcium and potassium into the heart muscle. This drug is one of the oldest treatments available for heart failures and is obtained from the 'Foxglove' plant. (Onalan et al.,2007,pp.1726-32)

Lanoxin should be avoided in case of slow heart beat rates, kidney problems, allergic reactions, etc. Nowdays, Lanoxin is no longer used for first line treatment of Atrial Fibrillation because of the following reasons:

← It may sometimes be toxin, depending on the person.

← Sometimes lead to very slow heart rate (Friberg et al., 2005, pp.666-72)

← Causes heart rhythm disturbances

← Causes visual impairments

Ques 4. Two days after her operation Mrs. Lim's PCA removed.

She is recommenced on QID Paracetomol 1 gram and QID (PRN) endone 5mg. Discuss the action of both drugs related to pain. What are the potential side effects or adverse reactions that you would need to discuss with Mrs Lim prior to administration. What is the benefit of regular Paracetomol compared with PRN administration?

Mrs Lim was discharged home 8 days after her operation. Her wound was reddened with a purulent discharge. She was commenced on Cephalexin QID and home care nurses arranged to call for wound check the following day.

Mrs Lim was also give discharged home on 8mg of Warfarin (Marevan) daily and commenced on QID Salbutomol puffers. You must provide her with education surrounding these discharge medications

Ans 4. Paracetamol is an analgesic and also an antipyretic. Similarly, endone is also used as a pain killer, in case of postoperative pain relief. These painkillers work by inhibiting the synthesis of prostaglandins (Garry,G. Kieran,S., 2005). Paracetamol is a good painkiller and is less likely to cause side effects. It has very weak anti inflammatory action. Its antipyretic effect is attributed to its ability to inhibit COX in the brain. Recent research shows that paracetamol decreases pain and fever by inhibiting the COX-3 in the brain. Paracetamol is almost completely absorbed from the gastrointestinal tract, after about 10- 60 minutes from the oral administration. It is metabolised predominantly in the liver and also excreted in the urine. Glucuronide and sulphate, the two metabolites of paracetamol are relatively safe compounds and thus, paracetamol is a relatively safe drug.

Surgery of the bowel is a major surgery and is linked to excessive pain and problems of wound infection. Mrs. Lim was given paracetamol and endone for the pain. However, as she suffered from discharge from the wound, she was given cephalexin. A discharge, along with a red and inflamed wound often indicates infection. Cephalexin is usually given in cases when a bacterial infection is suspected. However, it may lead to diarroheae, fever, cough, pale or yellow skin, bleeding, etc. (Högestätt, Jönsson & Ermund, 2005, pp.31405-12)

Mrs. Lim was alos given Warfarin and Salbutamol, to be taken daily after discharge from the hospital. Warfarin is basically used to prevent blood from clotting. Whereas, Salbutamol is a short acting receptor used for relief of bronchospasm. As Mrs.Lim was suffering from Asthma, she was given Salbutamol as a preventive measure.

Ques 5. Detail what you would say to Mrs Lim regarding the use, action, potential adverse or sid e effects and necessary precautions for her discharge medications. Provide a scientific rationale for your answer.

Ans 5. To transfer a patient from the hospital to home requires a lot of care and sensitivity. It is very important to give the patient a good and complete information regarding medication, while discharging. Telephone calls, along with a written list of discahrge medications is an important aspect (Jessop et al., 2010, pp.117-122). The information regarding a change should be well communicated to the patient and also reasons should be made clear to the patient. Timely medication reviews is also an important aspect of discharge medication. A patient should be made comfortable and complete information should be conveyed in a polite and cordial manner.

In case of Mrs. Lim, as she is an old woman, the medications have to be chosen with care keeping in mind the other problems that she has been facing and also the information has to be conveyed in a manner that she completely understands.

The process of conveying information would be as follows:

Mrs.Lim, hoping that you recover soon and in the right manner. For this, an important aspect is the timely dose of medication and also some precautions that need to be taken in order to avoid any complications in the future. Since, you are also suffering from Asthma and Atrial fibrillation, care has to be taken and precautionary drugs need to be given to you.

Since sometimes drugs react with each other, care has been taken while choosing drugs for your prescription. Given below is a list of drugs which need to be taken regularly and for quick recovery. Some precautionary drugs are also included in the plan.

As the bowel operation done is a major surgery, pain is experienced after the operation procedure. For this, Paracetamol 1mg and Endone 5mg need to be taken regularly, in over to avoid extreme pains and to also reduce inflammation in the body.These need to be taken regularly at an appropriate time. However, care needs to be taken and make sure that you eat these anaelgesics only after a meal.

As you are already suffering from wound swelling and redness, a bacterial infection is suspected. For this, Cephalexin has to be taken. It is an important antibiotic and should never be missed, or else infection may be increased.

As you are already suffering from Asthma and Atrial Fibrillation, medicines namely, Salbutamol for Bronchial problem and Warfarin and Amiodarone should be taken on time. These precautionary medicines are very important for the proper healing of the wound. Also, the pain killers and antibiotic may cause some cough and respitratory problems, which would be taken care of with the use of Salbutamol.

Timely and proper dosage of medicines is very important for quick recovery. Since you are also 70 years of age, extra care needs to be taken and also precautions need to be taken. Since a bowel surgery is a major operation, care needs to be taken for the following:

← Wound infections

← Intra abdominal infection

← Bleeding

← Urinary infections

← Erratic bowel activity, etc.

In case of any problem, a physician should be consulted and a nurse should be called for proper care. Moreover, for any other drug, except for those mentioned, a physician should be consulted. No drug intake should be stopped without a physician's advice. Proper dosage and precautions are vital components for quick recovery. In case of emergency, a physician should be consulted and no medicine should be taken on your own. In case of any allergic reaction or infection, consult your doctor before any step.

References:

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Friberg, J, Buch, P, Scharling, H, Gadsbphioll, N & Jensen, G.B. (2005). "Rising rates of hospital admissions for atrial fibrillation", Epidemiology, 14, (6), 666–72.

Hirohata, Shunsei , Nagai, Tatsuo , Asako, Kurumi , Tomita, Tetsuya , Yoshikawa & Hideki. (2011).Clinical Immunology, 140 (3), 276-283.

Högestätt, E.D, Jönsson, B.A, Ermund, A. (2005). "Conversion of acetaminophen to the bioactive N-acylphenolamine AM404 via fatty acid amide hydrolase-dependent arachidonic acid conjugation in the nervous system", J. Biol. Chem., 280, (36), 31405–12.

Jahangir, A, Lee, V, Friedman, P.A., Trusty, J.M., Hodge, D.O., Kopecky, S.L., Packer, D.L., Hammill,S.C., Shen, W.K. & Gersh, B.J. (2007)."Long-term progression and outcomes with aging in patients with lone atrial fibrillation, a 30-year follow-study",Circulation, 115, (24), 3050–6.

Jessop, David, S,.,Fassold, Alexander, Wolff, Christine, Hofbauer, Rafael , Chover-Gonzalez, Antonio,Richards, Louise J. , Straub & Rainer H.(2010). Annals of the New York Academy of Sciences, 1193, (1), 117-122.

Singh, B.N., Connolly, S.J. & Crijns, H.J. (2007). "Dronedarone for maintenance of sinus rhythm in atrial fibrillation or flutter", N. Engl. J. Med., 357, (10), 987–99.

Onalan, O, Crystal, E, Daoulah, A, Lau, C, Crystal, A, Lashevsky, I. (2007). "Meta-analysis of magnesium therapy for the acute management of rapid atrial fibrillation", Am. J. Cardiol., 99, (12), 1726–32.