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Students are required to submit a critical discussion paper related to the nursing management of Mr Ferguson’s case study below:

The critical discussion paper should address the following issues:

  1. Describethe patient’s presenting problem focusing on the pathophysiological issues.

  2. Reviewand use of literature to explain the pharmacokinetics of the prescribed medications and their indicati

  3. Discussthe nursing management appropriate for the patient including management of the adverse effects of the medication(s)  using evidence-based literatur

  4. Describein detail the information you would share with the patient and how you will educate the patient about the interactions and long term effects of the medications prescribed in the ED?

Presenting problem for patient

While engaging in planning care for critically ill patient, understanding links between the pathology of health issues is important to prescribe relevant medication to patient. The understanding regarding the pharmacokinetics of medication is important to promote efficacy and safety of medicines.  Knowledge regarding different factors that affect the pharmacokinetics of drugs helps health care professional to appropriately educate patient and maintain their health and safety. The main purpose of this paper is to review the case scenario of Mr. Fergusion, a 76 year old male with symptoms of chest heaviness and discuss about the pathophysiology behind the condition. The evidence also provides insight into pharmacokinetics of the prescribed drugs for the patient and the nursing management step to manage adverse effects and long term effects of the medication.  As evident from the case study, the client Mr. Ferguson is suffering from symptoms outlining severe chest heaviness, which has been occurring since the last 2 hours. His condition of chest heaviness has been associated with further clinical symptoms such as shortness of breath, paleness and condition of excessive sweating or diaphoresis, possibly due to the effects of a drug. While Glyceryl Trinitrate taken by Mr. Ferguson is a drug commonly used to treat chest pain, exhibition of excessive sweating is often characterised as its major side effects. Hence, for the treatment, a revised medication report has been identified for Mr. Fergusson which includes Aspirin, Heperain infusion, Morphine Sulphate and Fentanyl. Hence, the following report aims at extensively discussing the pharmacokinetics of the above prescribed medications.

This paper is centred around the case scenario of Mr. Ferguson, a 76 year old man who was admitted to the emergency department with complains of a history of chest heaviness. The first emergency treatment that was provided to him included self-administration of glyceryl trinitrate pump spray. The patient was also pale, diaphoretic and short of breath on arrival to the bed. His symptoms mainly indicate the possibility of myocardial infarction. Acute myocardial infarction is a clinical condition associated with disruption in blood flow to the muscle and blockage due to build up of plaque in the arteries. Chest pain is the most common presenting complaints of myocardial infarction followed chest tightness, sweating, anxiety and cough. Similar symptoms were identified for Ferguson too. Ferguson experienced chest heaviness and this might have occurred due to heavy chest pressure and increase in intensity of pain (Malik et al., 2013).

The main physiological change that is linked to myocardial infarction includes decrease in coronary blood flow.  Lack of oxygen supply to the myocardium is the etiology behind myocardial infarction. Inability to meet the oxygen demand results in cardiac ischemia. Artheoslerotic plaques develop in patient with myocardial infarction which eventually ruptures and lead to thrombosis and decrease blood flow in the coronary. The artherosclerotic rupture results in the activation of the inflammatory cascade. Monocytes and macrophages are released leading to thrombus formation and platelet aggregation. The physiological changes within the body are associated with reduced oxygen delivery to the coronary artery and an eventual decrease in the oxygenation of the myocardium. Apoptosis of the endocardium is the final result and this result in the manifestation of the symptoms of chest heaviness and chest pain in patients. Hence, the above discussion shows the pathological issues that have resulted in chest heaviness and shortness of breath for Mr. Ferguson. In addition, shortness of breath is a high risk symptom for Mr. Ferguson as evidence show that as complaints of dyspnoea predicts higher mortality rate compared to chest pain in patients suspected to be suffering from myocardial infarction in emergency setting (Bøtker et al., 2016).

Pharmacokinetics of prescribed medication

In response to the clinical issues identified for Mr. Ferguson, he was prescribed Aspirin 300mg Po, Morphine sulphate IV 2. mg, heparin infusion and Fentanyl. This section discusses about the rationale behind prescribing these medications and the pharmacokinetics surrounding each drugs.

The first medication that was prescribed to Mr. Ferguson included Aspirin 300 mg. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) that is mainly prescribed to patient for pain relief. In case of Mr. Ferguson, he was prescribed Aspirin not for pain relief, but for preventing blood clots as he was suspected to be at risk of myocardial infarction. Low dose of aspirin is given to millions of patient worldwide for preventing CVD and the main mechanism behind its action is the inhibition of the platelet activation and aggregation process. The action of the drug leads to irreversible inhibition of the cyclo-oxygenase enzyme thus preventing the synthesis of prostaglandins (Dai & Ge, 2011). Aspirin is absorbed rapidly from the stomach and intestine and transformed into salicylate in the stomach, blood and liver. The oral bioavailability of the drug is 68% and the clearance is 39l/h. Salicylates metabolites left behind are excreted in the urine (Lanas, 2016). Negligible research has been documented considering the long term effects of aspirin. While short term side effects of aspirin has been associated with excessive gastrointestinal bleeding, long term implications have often been associated with a reduction in the risk of acquiring cancers in the oesophagus, bowel and stomach (Rodriguez et al., 2016).

Morphine sulphate has been given to Mr. Ferguson for the management of severe pain associated with myocardial infarction. Chest pain is a common symptom in patients with myocardial infarction and intravenous morphine sulphate is the common drug of choice for pain relief in such patients. Use of this drug will help to reduce symptom of dyspnoea and anxiety for Mr. Ferguson (Parodi, 2016).The pharmacokinetics of the drug can help to understand the best dose and nursing plan of care for Mr. Ferguson. The mechanism of action of morphine sulphate is associated with its binding to opioid mu-receptors, prevalent primarily in the spinal cord and cortical areas of the brain such as the hypothalamus and thalamus, resulting in effects of sedation and analgesia (Rubio-Martinez et al., 2017). Morphine sulphate is absorbed variably during oral administration and reliable absorption occurs through rectum and subcutaneous sites. Systemic absorption occurs through epidural administration. Morphine is widely distributed across the placenta and in breastmilk. Protein binding may take place in infants and adults to some extends. The drug is metabolized by the liver and excreted renally (Valkenburg et al., 2016).  During nursing management of patient, consideration of the adverse effect of the drug will be important. The long term effects of morphine sulphate include feelings of sleepiness, constipation, hypotension and reduced rates of respiration, vomiting and nausea or physical deformities or withdrawal symptoms in the foetus of pregnant women (Chou et al., 2015).

Other two medications that was prescribed to Mr. Ferguson included heparin infusion and Fentanyl.Heparin use is indicated in the prevention of clotting and for treatment of prophylaxis. Heparin is used as part of anti-coagulant therapy to treat patient with acute myocardial infarction. The mechanism of action of heparin associated with its activity as an anticoagulant, through the prevention of coagulation cofactors such as fibrin and thrombin – which proves to be beneficial for reduction of clot accumulation or embolism prevalent in patients suffering from myocardial infarction (Salem et al., 2015). The knowledge of the pharmacokinetics of heparin is important to take decisions regarding the dose and safety consideration for patient. The main challenge associated with the use of heparin is that it cannot be absorbed through the mucosa. Hence, it needs to be given parenterally. The onset of action through IV infusion is immediate. The volume of distribution of the drug is 40-70mL/min (Lau, Barnes & Streiff, 2018). . However, considering the dose for obese patient is important as it does not distribute into adipose tissues. Heparin has also been associated with a number of long term effects such as bluish discoloration of the skin, itchiness of the feet, bruises or excessive bleeding and feelings of warmth, redness, pain or irritation concerning the skin area where the drug is injected (Jianqui et al., 2017).

In addition, Fentanyl was prescribed to patient for pain relief. It is an opioid drug that works to have an effect on the neurotransmitter dopamine. Review of its pharmacokinetics can give an insight regarding the method in which the drug is absorpted, distributed and excreted. Fentanyl can be absorbed by ingestion, skin contact, oral exposure or via inhalation. Hence, it can be administered transdermally or intramuscularly or intravenously. The drug is primarily excreted in the urine and metabolized by CYP 3A4 to inactive metabolites (Kuip et al., 2017). The mechanism of action of Fentanyl is associated with that of analgesic and sedartive medications similar to that of morphine, through its binding to opioid mu-receptors. However, the drug produces stronger effects as compared to morphine (John et al., 2017). However long term use of the drug has been associated with multiple organ failure due to decreased oxygen supply, detrimental mental health, seizures, hallucinations, weakness, alterations in the pulse rate and decrease in the rate of respiration (Mercadante et al., 2015).

Chest pain and shortness of breath is the major presenting health issue for Mr. Ferguson. The review of his vital stats reveal high blood pressure (172/86), irregular heart beat (103 bpm) and increased breathing rate. The normal breathing rate is 12 to 20 breaths per minute and Mr. Ferguson’s breathing rate was 24 breaths per minute. Hence, one of the major nursing care priority will be to manage acute chest pain, reduce anxiety and increase knowledge of patient related to the condition. The pharmacological intervention like pain medication will play a role in the management of pain. In addition, anxiety can be reduced by means of education as patient will be more confidence once he is aware about the disease and the rationale behind each treatment.

For nursing care priority of increased knowledge related to myocardial infarction, the care plan is to assess patient’s understanding about his condition and create instruction plan to make Mr. Ferguson aware about risk factors, dietary and activity restrictions that is needed for him to prevent any complication. Another vital part of the education plan is to educate Mr. Ferguson about adverse effects of each prescribes medication so that these side effects are managed at the right time. For example, Mr. Ferguson has been prescribed Morphine sulphate and some of the adverse effect associated with the use of this drug are dizziness, headache, blurred vision, hypotension, nausea, vomiting and urinary retention (Vallerand, 2018). Hence, the nursing care strategy is educate patient about the adverse effects and advice patient to report if he experiences such adverse effect. Other extra precaution needed by nurse will be to assess level of conscious, BP, pulse and respiration of patient periodically after the administration of the drug. Mr. Ferguson will also be advised to change position slowly to prevent risk of fall due to dizziness and low BP (ABDI & Basgut, 2016). Similar type of action is needed for adverse effects found for all the prescribed medications.

There are chances of interaction and long-term effect of each prescribed drugs and educating Mr. Ferfuson about this is important as he might be taking other drugs which would create complications for patient. In regard to the four medications prescribed, I would provide the following information to Mr. Fergusion regarding the interactions and long term effect of the drug:

Aspirin: Using this medication is harmful if used in case of disorders like ulcer. In the long term, it can increase risk of intestinal bleeding in patient. Hence, patient should be advised to avoid regular use in the long term (Huang et al., 2011).

Morphine sulphate: Morphine is a drug that can lead to long term addiction and engagement in harmful activities. Hence, long term use should be discouraged.

Low molecular weight heparin: Heparin is contraindicated in patients with decreased platelets, bleeding, haemophilia and eye surgery. Hence, patient should be made aware of this (Vallerand, 2018).

Fentanyl: Drug-drug interaction can be send when used with other CNS depressants, CYP 31A4 inhibitors and CYP 3a4 inducers. Hence, patient medication should be reviewed before contining this for Mr. Fergusoon. It is also contraindicate in patients with known hypersensitivity and liver failure (Ramos-Matos & Lopez-Ojeda, 2017).a

Conclusion:

The paper summarized the health issues and the pharmacokinetics surrounding each medication for patient. The discussion related to the pharmacokinetics of each drugs helped to understand the rationale behind mode of administration and dose consideration for MR. Ferguson. Patient education is also considered a vital part of care plan as many medications are associated with adverse effects and long term-effects. Hence, making patient aware about this is important to prevent long-term complications.

References:

ABDI, A., & Basgut, B. (2016). An Evidence-Based Review of Pain Management in Acute Myocardial Infarction. pain, 2, 3.

Bøtker, M. T., Stengaard, C., Andersen, M. S., Søndergaard, H. M., Dodt, K. K., Niemann, T., ... & Terkelsen, C. J. (2016). Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scandinavian journal of trauma, resuscitation and emergency medicine, 24(1), 15.

Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., ... & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine, 162(4), 276-286.

Dai, Y., & Ge, J. (2011). Clinical use of aspirin in treatment and prevention of cardiovascular disease. Thrombosis, 2012.

Huang, E. S., Strate, L. L., Ho, W. W., Lee, S. S., & Chan, A. T. (2011). Long-term use of aspirin and the risk of gastrointestinal bleeding. The American journal of medicine, 124(5), 426-433.

Jianqiu, L. U., Song, S., Xia, W., Danqi, L. I., Liang, H., & Jianh, J. (2017). Expression of thrombolytic effect of urokinase plus heparin mixed with different sealing methods on long-term dialysis catheter. Chinese Journal of Biochemical Pharmaceutics, 37(6), 51-52.

John, R., Ranjan, R. V., Ramachandran, T. R., & George, S. K. (2017). Analgesic efficacy of transverse abdominal plane block after elective cesarean delivery–Bupivacaine with fentanyl versus bupivacaine alone: A randomized, double-blind controlled clinical trial. Anesthesia, essays and researches, 11(1), 181.

Kuip, E. J., Zandvliet, M. L., Koolen, S. L., Mathijssen, R. H., & van der Rijt, C. C. (2017). A review of factors explaining variability in fentanyl pharmacokinetics; focus on implications for cancer patients. British journal of clinical pharmacology, 83(2), 294-313.

Lanas, A. (2016). NSAIDs and Aspirin. Springer International Publishing Switzerland.

Lau, J. F., Barnes, G. D., & Streiff, M. B. (Eds.). (2018). Anticoagulation Therapy. Springer.

Malik, M.A., Khan, S.A., Safdar, S. and Taseer, I.U.H., 2013. Chest Pain as a presenting complaint in patients with acute myocardial infarction (AMI). Pakistan journal of medical sciences, 29(2), p.565.

Mechanic, O. J., & Grossman, S. A. (2017). Myocardial Infarction, Acute. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459269/

Mercadante, S., Vellucci, R., Cuomo, A., Adile, C., Cortegiani, A., Valle, A., ... & Casuccio, A. (2015). Long-term efficacy and tolerability of intranasal fentanyl in the treatment of breakthrough cancer pain. Supportive Care in Cancer, 23(5), 1349-1354.

Parodi, G. (2016). Editor’s choice-chest pain relief in patients with acute myocardial infarction. European Heart Journal: Acute Cardiovascular Care, 5(3), 277-281.

Ramos-Matos, C. F., & Lopez-Ojeda, W. (2017). Fentanyl. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459275/#_article-21694_s2_

Rodríguez, L. A. G., Martín-Pérez, M., Hennekens, C. H., Rothwell, P. M., & Lanas, A. (2016). Bleeding risk with long-term low-dose aspirin: a systematic review of observational studies. PLoS One, 11(8), e0160046.

Rubio-Martínez, L. M., Rioja, E., Martins, M. C., Wipawee, S., Clegg, P., & Peffers, M. J. (2017). Local anaesthetics or their combination with morphine and/or magnesium sulphate are toxic for equine chondrocytes and synoviocytes in vitro. BMC veterinary research, 13(1), 318.

Salem, J. E., Sabouret, P., Funck?Brentano, C., & Hulot, J. S. (2015). Pharmacology and mechanisms of action of new oral anticoagulants. Fundamental & clinical pharmacology, 29(1), 10-20.

Valkenburg, A. J., Calvier, E. A., van Dijk, M., Krekels, E. H., O’hare, B. P., Casey, W. F., ... & Breatnach, C. V. (2016). Pharmacodynamics and pharmacokinetics of morphine after cardiac surgery in children with and without down syndrome. Pediatric Critical Care Medicine, 17(10), 930-938.

Vallerand, A. H. (2018). Davis's drug guide for nurses. FA Davis.

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