PEER

RESPONSES WEEK 1

NURS 6521 PHARMA

Yarima Palmero Castellanos

n
Pharmacokinetics and Pharmacodynamics

Patient Description

A 67-year-old patient, Jason, was admitted to the hospital’s emergency department (ED) with a hip fracture. The patient’s medical history showed that he was ona low dosage of naproxen, metoprolol, pantoprazole, and aspirin. After conducting a series of assessments and physical examinations, the caregiver diagnosed the patient with a hip fracture and hip bursitis. The caregiver administrated a combined dose of Nonsteroidal anti-inflammatory drug (NSAID), naproxen, and a high dose of aspirin to reduce inflammation and relieve the patient from extreme pain(Monzón et al., 2010). Nevertheless, the patient did not exhibit any signs of improvement. Three days later, the patient reported to the hospital’s ED complaining of severe pain in the lower abdomen. Upon examination, Jason showed signs of gastrointestinal bleeding, which upon investigation was linked to his earlier medications. The caregiver administered an additional dose of citalopram, but the patient did not show any improvement.As a result, the doctor ordered an MRI scan to determine the actual position of the hip fracture and decide on the way forward. The MRI scan indicated that Jason had a fracture on the intertrochanteric region, and the doctor recommended a partial hip replacement surgery. Following the surgery, the patient showed significant improvement and rehabilitation after undertaking physical therapy sessions.

Factors that may have influenced the Patient’s Pharmacokinetic and Pharmacodynamic Processes

The patient’s adverse response to NSAID and aspirin and citalopram before the surgery can be attributed to age-related factors, which predisposed him to further complications. For older patients like Jason, the risk of reduction in renal function is relatively higher than younger patients. The administration of a combined dose of naproxen and metoprolol could have increased the risk of reduced renal function in Jason. The risk is even higher following the administration of naproxen and aspirin, with some patients experiencing gastrointestinal bleeding. Older patients receiving a combined dose of NSAID and a high-level dose of aspirin medications stand at an elevated risk of experiencing reduced renal function and gastrointestinal bleeding. Age-related differences can account for the increased predisposition to hypoglycemic agents in older patients. In such patients, hypoglycemia may present as a cognitive change. Older patients tend to show blunted beta-adrenergic response than younger patients. The problem is further exacerbated by the co-administration of drugs like metoprolol, leading to reduced renal function and other complications.

Personalized Care Plan for Jason

A personalized care plan for hip fractures should be holistic. Care providers must consider the patient’s medical and rehabilitation needs before deciding on the way forward. Considering the patient’s social and psychological factors like coping strategies, self-efficacy, and degree of control is imperative while developing a care plan. The treatment and rehabilitation should produce positive outcomes to ensure that the patient can live independently after recovery and minimize the cost associated with readmissions considering their age (Barberi & Mielli, 2018). Care should begin with providing a comprehensive ortho-geriatric examination on the patient. The doctor should also give rapid patient optimization before surgery to ensure that the patient is fit for surgery. Identifying a patient’s rehabilitation goals before deciding what treatment plan to use can go a long way in ensuring full recovery and long-term wellbeing (Barberi et al., 2018). For example, asking a patient whether he has family support can determine the type of rehabilitation given after treatment. Additionally, healthcare providers should consider liaison with support services, for example, mental health clinics and the department of social services, where patients can access additional services to facilitate full rehabilitation.

References

Barberi, S., & Mielli, L. (2018). Rehabilitation and discharge. Fragility Fracture Nursing, 125-136. https://doi.org/10.1007/978-3-319-76681-2_10

Monzón, D. G., Vazquez, J., Jauregui, J. R., & Iserson, K. V. (2010). Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. International journal of emergency medicine, 3(4), 321-325. https://doi.org/10.1007/s12245-010-0234-4

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Diana Nelson

Initial Discussion- week 1

COLLAPSE

Working in substance abuse for the last several years, I have come across numerous cases where the patient has many reasons that may influence the pharmacokinetic and pharmacodynamic processes. When detoxing a patient from alcohol, the patients age, gender, and presence of liver disease are taken into consideration when prescribing the appropriate detox medication to use. Benzodiazepines are safe, effective and the preferred treatment for alcohol withdrawal (Sachdeva, 2015). Choosing a benzodiazepine depends on selection of preferred pharmacokinetic properties in relation to the patient being treated (Sachdeva, 2015). The most used benzo’s for alcohol detoxification is chlordiazepoxide, diazepam (which are long-acting) and lorazepam, oxazepam (which are short/intermediate acting).

Although the long-acting agents have a greater half-life and can provide a smooth course of treatment without the risk of rebound symptoms that occur late during withdrawal. A disadvantage of chlordiazepoxide and diazepam is that the long-half lives and presence of active metabolites make it likely that drug accumulation will occur in a patient with liver disease (Sachdeva, 2015). Even though probably every organ in the human body is capable of metabolizing drugs, the liver and small intestines serve as the dominant sites of expression of the major drug metabolizing enzymes (Intechopen, n.d.).

In developing a personalized plan of care for a patient in need of alcohol withdrawal management, a history of liver disease would have to be established. Epidemiological studies have identified a number of factors that contribute to the risk of developing cirrhosis. Moderate alcohol consumption, age older than 50 years, and male gender are examples that increase cirrhosis risk (Liver Disease Case Studies: Case Study Level 1 – Alcoholic Cirrhosis; Alcohol Withdrawal – Pharma Mirror Magazine, 2013). For example, a 58-year-old Caucasian male with a 20-year daily alcohol consumption history, who presents with distended abdomen and in active withdrawal. Prescribing a long-acting benzodiazepine would not be appropriate or effective. Starting with a short-acting benzo like lorazepam would be more effective in controlling his withdrawal symptoms and preventing seizures. Lorazepam should be used for this patient due to his severe liver dysfunction, and his high risk of experiencing serious medical consequences following sedation (Sachdeva, 2015). Lorazepam has no active metabolites, and its metabolism is not much affected in the liver (Sachdeva, 2015).

References

Detoxification of drug and substance abuse | intechopen. (n.d.). https://www.intechopen.com/books/medical-toxicology/detoxification-of-drug-and-substance-abuse

Liver disease case studies: Case study level 1 – alcoholic cirrhosis; alcohol withdrawal – pharma mirror magazine. (2013, March 22). Pharma Mirror Magazine. https://www.pharmamirror.com/education-center/pharmacy-case-study/liver-disease-alcoholic-cirrhosis-withdrawal/

Rosenthal, L.D. & Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier.

Sachdeva, A. (2015). Alcohol withdrawal syndrome: Benzodiazepines and beyond. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. https://doi.org/10.7860/jcdr/2015/13407.6538

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CLASS NURS 6501 NURS 6501: Advanced Pathophysiology

2 days ago

Edelis Morales

Discussion: Alterations in Cellular Processes

COLLAPSE

In the case study provided, it is evident that the patient has hyperkalemia, necrosis, and substance abuse. Since the patient had a positive response to naloxone which was administered in the field it is evident the patient had abused an opioid. According to Florez et al. (2017), desomorphine is an injectable opioid derivative that has been associate with thrombophlebitis, tissue necrosis, and gangrene. The patient in the case study on examination had a large amount of necrotic tissue over the greater trochanter as well as his forearm.

Opioid addiction lacks a clear inheritance pattern although many people have a family history of opioid addiction or other substance addiction (Crist et al., 2019). According to Karch (2019), there are specific variations of the gene makeup which leaves some individuals with a higher risk for addiction. DNA has been found to produce some proteins commonly found in addiction when certain drugs are used. It is also thought that genes do influence receptor types in the brains, how quickly drugs are metabolized in their bodies, and how their bodies react to different drugs.

Intravenous opioids abuse is associated with depressed cardiac and respiratory function, compartment syndrome, and rhabdomyolysis. The patient’s cells have been injured since they are having necrosis on the greater trochanter and forearm which are common injection sites. Rhabdomyolysis is frequently used correspondently with myoglobinuria that follows muscle protein myoglobin present in urine and persons who have been unresponsive or immobile for a long time. Both myoglobinuria and rhabdomyolysis can result in hyperkalemia secondary to the removal of intracellular sodium into the circulating blood which can result in metabolic acid, acute renal failure, and disseminated intravascular coagulopathy. Hyperkalemia affects the cardiovascular system also which can be the reason the patient had prolonged PR interval and peaked T wave. The patient had pain on the right hip and forearm, and pain is a clinical manifestation that makes up the triad together with weakness and dark urine.

According to McCance & Huether (2019), gender plays a very key role when it comes to lab values of CK and what would signify rhabdomyolysis. If the patient was elderly, then it could have altered the management for the patient significantly. If the naloxone that the patient received in the field failed to work, an alternative for it would have been required is to first secure the patient’s circulation and the airway.

Hyperkalemia and rhabdomyolysis are manageable in the early stages. Healthcare workers should be familiar with substance abuse and the side effects of each substance that is abused to be able to manage patients effectively. Also, they should be able to understand cellular processes and alterations to be able to ensure that the patient receives adequate care.

References

Crist, R. C., Reiner, B. C., & Berrettini, W. H. (2019). A review of opioid addiction genetics. Current opinion in psychology, 27, 31-35.

Florez, D. H. Â., dos Santos Moreira, A. M., da Silva, P. R., Brandão, R., Borges, M. M. C., de Santana, F. J. M., & Borges, K. B. (2017). Desomorphine (Krokodil): An overview of its chemistry, pharmacology, metabolism, toxicology and analysis. Drug and alcohol dependence, 173, 59-68.

Karch, S. B. (Ed.). (2019). Drug abuse handbook. CRC press.

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier

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2 days ago

Russell Ray

Ray, R Week 1 discussion

COLLAPSE

Case Study

A 27-year-old patient with a history of substance abuse is unresponsive by emergency medical services (EMS) after being called by the patient’s roommate. The roommate states that he does not know how long the patient had been lying there. The patient received naloxone in the field and has become responsive. He complains of burning pain over his left hip and forearm. Evaluation in the ED revealed a large amount of necrotic tissue over the greater trochanter as well as the forearm. EKG demonstrated prolonged PR interval and peaked T waves. Serum potassium level 6.9 mEq/L.

The patient was unresponsive; we do not know the length of time before EMS arrival that the patient was down. We can assume that the patient had a less than optimal respiratory pattern during the time of unresponsiveness. We know that opiates and medications responding to Narcan administration also decrease respiratory effort and drive. The patient may have been hypoxic for the entire time of the unresponsive episode. We do not have a complete history for the patient, but we have a high index of suspicion for malnutrition based on drug abuse history. (Liu, et al., 2010). Combining an already poor state of nutrition coupled with a hypoxic environment is an ideal situation for cellular injury.

The patient was found down in a position not reported in the case study, but from the reports of pain to the left hip and left arm, we may infer that the patient was lying for an extended period on his left side. As with elderly patients suffering from decubitus ulcers, this patient has suffered tissue injury due to impeded blood flow to the areas in contact with the floor , causing tissue hypoxia and cellular damage due to inadequate cellular respiration and a build-up of cellular waste in the anaerobic state created by the lack of circulation to the area and a preexisting global hypoxic state from the drug overdose. (Krouskop, et al., 1978). The waste build-up is a byproduct of the limited function of the lymphatic systems in the affected area and tissue

perfusion loss. This damage leads to cellular death and an increased release of cellular contents into the bloodstream and the surrounding tissues. The Vasculature itself is weakened and becomes more permeable locally, allowing for the “vascular leak” of these same cellular waste products into the local tissue. (Malinoski, et al., 2004). The damage to the area’s muscles causes the releases of myoglobin as well as potassium into the circulator system once the patient is revived and the pressure is removed from the affected areas allowing the systemic release of the byproducts of the cellular injury. This increases the amount of serum potassium within the bloodstream and is responsible for the EKG changes noted in the assessment. (Malinoski, et al., 2004).

The patient could be quickly assessed for diabetes via a capillary blood glucose test. Diabetes is a known genetic disorder that causes decreased perfusion to the capillary beds and sclerosis of the vasculature. (Kirpichikov & Sowers, 2001). Secondly, the patient should be continually assessed for the presence of rhabdomyolysis, and particular attention should be paid to the patient’s kidney function. This is needed due to the extended time the patient spent immobile and the damage the tissues took during this time. Rhabdomyolysis occurs when there is a significant muscular injury resulting in the release of massive amounts of myoglobin, essentially “clogging.” the kidneys and impair their ability to function. Elevations in total Creatinine Kinase is an indicator of this potentiality. (Stahl, et al., 2019).

Gender differences potentially adding to or preventing these occurrences are supposition only due to lack of defining characteristics within the case study. We may suppose that females’ increased subdermal fat layer may have prevented the severity of the pressure injury. Aside from that, we may hope that the female of the species has more commonsense than the male and would not have overdosed on a substance reactive to Narcan in the first place.

References

Kirpichnikov, D., & Sowers, J. R. (2001). Diabetes mellitus and diabetes-associated vascular

disease. Trends in endocrinology & metabolism, 12(5), 225-230.

Krouskop, T. A., Reddy, N. P., Spencer, W. A., & Secor, J. W. (1978). Mechanisms of decubitus

ulcer formation—an hypothesis. Medical hypotheses, 4(1), 37-39.

Liu, S. W., Lien, M. H., & Fenske, N. A. (2010). The effects of alcohol and drug abuse on the

skin. Clinics in dermatology, 28(4), 391-399.

Malinoski, D. J., Slater, M. S., & Mullins, R. J. (2004). Crush injury and

rhabdomyolysis. Critical care clinics, 20(1), 171-192.

Stahl, K., Rastelli, E., & Schoser, B. (2019). A systematic review on the definition of

rhabdomyolysis. Journal of neurology, 1-6.