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polypharmacy patient case study - Coggle Diagram
polypharmacy patient case study
medications
Spironolactone (McKenna & Lim, 2014)
Patient's dose: 12.5mg once daily
indication
Oedema secondary to Heart Failure
normal dose range
100-200mg daily PO
side effects
Dizziness, nausea, vomiting, diarrhoea, headache
route
Oral
mechanism of action
Inhibits aldosterone dependant sodium exchange channels. Leads to increased sodium and water excretion.
contraindication
anuria, renal impairment, hyperkalaemia, hyponatremia.
interaction
Lithium, Nonsteroidal anti-inflammatory, Digoxin, Cholestyramine, Acetylsalicylic acid
Warfarin (McKenna & Lim, 2014)
Pts dose varies daily
indication
Atrial Fibrillation
normal dose range
2-10mg daily
side effects
bruises, nosebleeds, bleeding gums, heavier bleeding, discoloured urine, bloody stools, vomiting/coughing blood
route
Oral
mechanism of action
inhibits the vitamin K. Through this mechanism, warfarin can reduce functional vitamin K reserves and reduces active clotting factors
contraindication
operation on the spine, cancer, polycythemia vera, eye surgery, caloric undernutrition, low vitamin K levels, anemia, increased risk of bleeding due to clotting disorder.
interaction
Aspirin, Acetaminophen, laxatives, some antibiotics, Ibuprofen, medications that treat abnormal heart rhythms
Entresto (McKenna & Lim, 2014)
Patient's dose: Sacubitril 24.3mg + valsartan 25.7mg once daily
normal dose range
24mg/26mg, 49mg/51mg or 97mg/103mg
side effects
Hypotension, hyperkalaemia, cough, dizziness, and kidney failure.
indication
Heart failure
route
oral
mechanism of action
Sacubitril is a neprilysin inhibitor and valsartan is an angiotensin receptor blocker. Valsartan inhibits the effects of angiotensin II by selectively blocking the AT1 receptor. Sacubitril plus valsartan enhances the beneficial response of the neurohormonal system of the heart while inhibiting the damaging effects of the renin-angiotensin-aldosterone system.
contraindiaction
low sodium in blood, high potassium in blood, renal artery stenosis, low BP, liver conditions, renal impairment, angioedema and pregnancy.
interaction
liskiren, lithium, drugs that increase potassium in the blood
Atorvastatin (McKenna & Lim, 2014)
Patient's dose 20mg once daily
side effects
Diarrhoea, heartburn, gas, joint pain, forgetfulness or memory loss, confusion
route
Oral
mechanism of action
Atorvastatin is a inhibitor of HMG-CoA reductase. It prevents the conversion of HMG-CoA to mevalonate, statin medications decrease cholesterol production in the liver.
normal dose range
20-80mg daily
indication
Heart Failure
contraindication
low thyroid hormones, alcoholism, brain hemorrhage, liver conditions kidney impairment, rhabdomyolysis, memory loss, high BSL, impaired liver, traumatic injury and pregnancy
interaction
aptomycin, gemfibrozil., cyclosporine, glecaprevir plus pibrentasvir, telaprevir, telithromycin, ritonavir
Bisoprolol (McKenna & Lim, 2014)
Patient's dose was 10mg, decreased to 2.5mg due to hypotension
mechanism of action
bisoprolol reduces the oxygen consumption of myocardial cells. B1 receptors are also present in the juxtaglomerular cells. By blocking these receptors, Bisoprolol leads to a decrease in the release of renin; as a result, it blocks the activation of the renin-angiotensin system.
contraindication
Depression, Acute heart conditions, Cerebrovascular disease, Hyperthyroidism, thyroid disease, thyrotoxicosis, diabetes mellitus, respiratory conditions, hypertension, renal conditions, pregnancy, breastfeeding.
route
Oral
interaction
Acebutolol, atenolol, betaxolol, carvedilol, celiprolol, clonidine, digoxin, diltiazem, esmolol, labetalol, metoprolol, nadolol, nebivolol, penbutolol, pindolol, propranolol, rivastigmine, sotalol, timolol and verapamil.
side effects
dizziness, nausea, headaches, cold hands or feet, constipation, diarrhoea
normal dose range
5-20mg daily 2.5 for decreased renal function
`indication
Heart Failure and Hypertension
Candestratan (McKenna & Lim, 2014)
Patient's dose: 4mg once daily
route
Oral
mechanism of action
blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues, such as vascular smooth muscle and the adrenal gland.
side effects
back pain, dizziness, fever, cough, sneezing, sore throat, runny nose, nasal congestion
contraindication
Hypersensitivity to any component of ATACAND, Pregnancy and lactation, hepatic impairment, cholestasis, diabetes mellitus, renal impairment
normal dose range
8-32mg daily
interaction
aliskiren, lithium, and ACE inhibitors
indication
Hypertension
Patient Profile
76-year-old male. New Zealand European.
Medical/Personal history
Heart failure with preserved ejection fraction, arterial fibrillation, ischemic heart disease and chronic kidney disease. Increased leg swelling since stopping Entresto two months prior due to acute kidney injury, gained 10kgs since. Lives with wife, usually independent.
Reason for admission
Experiencing shortness of breath and left sided chest pain. Admitted with fluid overload and ECG changes.
Scopes of Practice/ Laws and Acts
Medication Rights
Right medication, Right dose, Right time, Right route, Right patient, Right to refuse, Right form, Right evaluation, Right assessment, Right documentation. Medication checks: labels, expiry date, medication label against medication order, patient's allergies, measurements, calculations and recheck medication after dispensing and prior to administering (NZNO, 2018).
Nursing code of conduct
A set of standards defined by the Nursing Council of New Zealand which outlines the conduct or behaviour that nurses are expected to uphold. Failure to uphold these standards may lead to disciplinary investigation (NCNZ, 2012).
Medicines Act 1981 and it's associated
Medicines regulation Act 1984
Defines what a medication is and the requirements for the approval, manufacture, sale, distribution, classification, prescribing, advertising and dispensing of medicines. As well as licensing requirements for the medication's distribution chain, including pharmacies and wholesalers. Identifies who can prescribe medications and the legislative framework for prescribing prescription medications. The act also outlines the medicines control team which administers controls on the distribution chain of medications and controlled drugs within New Zealand and manages drug abuse containment issues (Ministry of Health, 2018).
The act outlines 4 classifications of medications; prescription medications, restricted medicines, pharmacy only medicines and general sale medicines (NZNO, 2018). Regulates medicines, medical devices and related products in New Zealand. It ensures that the medicines and products used within New Zealand are effective and safe to use (Medicines Regulations Act, 1984).
Misuse of Drugs Act 1975
A drug control law that includes provisions about the legal and illegal use of controlled drugs. Drugs that pose a very high risk are classified as a Class A drug; Drugs that pose a high risk are classified as Class B drugs; and drugs that pose a moderate risk are classified as Class C drugs (Misuse of Drugs Act, 1975). Nurses should have knowledge of the legislation regarding administration, storage and documentation of medicines and controlled drugs, as well as policies regarding these requirements (NZNO, 2018).
Nursing Council of New Zealand
competencies for registered nurses
Nurses are to practice in a culturally safe way, avoiding imposing prejudice and cares for patients in a way which respects their identity and right to hold personal goals, values and beliefs. When a nurse is competent, the patient is cared for in a safe manner and demonstrates the nurse's ability to understand and apply the principles of the Treaty of Waitangi to nursing practice (NCNZ, 2012).
Health and Disability Commissioner Act 1994
10 rights: 1. The right to be treated with respect. 2. Right to freedom from discrimination, coercion, harassment and exploitation. 3. Right to dignity and independence. 4. Right to services of an appropriate standard. 5. Right to effective communication. 6. Right to be fully informed. 7. Right to make an informed choice and give informed consent for treatments, including medications. 8. Right to support. 9. Rights in respect of teaching or research. 10. The right to complain (HDC, 2020).
Student nurse scope
Students must follow medication policies and procedures as well as policies and procedures of the clinical environment. All documentation must be co-signed by an RN and the student is to be under direct supervision when administering all medications. Transition students are not to administer IV controlled drugs, IV blood and blood products or handle central venous access devices, but can be the 3rd checker of these medications (TDHB, 2020). Student nurses are not regulated under New Zealand law, this means registered nurse remains responsible for the actions of the student (NZNO, 2018).
Health Practitioners Competence Assurance Act
2003
The act makes sure nurses are competent and fit to practice. It creates a framework for the regulation of nurses and other health care professionals in order to protect patients in situations where they may be at risk of harm due to professional practice (Ministry of Health, 2018)
Health Information Privacy Code 1994
A code of practice issued by the Privacy Commissioner under the Privacy Act which ensures extra protection for health information due to its sensitive nature (Ministry of Health, 2020). Sets specific rules for the health sector which covers health information that is collected, held, used and disclosed by health agencies. This code applies to all agencies and individuals who provide personal or public health and disability services (Privacy Commissioner, 2013).