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Question:

Briefly outline the main concepts identified in the case study

Describe the relevant pathophysiology evident from the case.  Use your understanding of the physiological processes to explain the clinical presentation of the case study.

Discuss the medications from the case and relate their mechanism of action. Using appropriate drug therapy references describe the effects of the drug therapy on the person described in the case study.

Describe your prioritised interventions for the case

Use your clinical reasoning to prioritise necessary person-centred interventions. Relate the interventions to addressing clinical issues related to the drug therapy regimen described in the case.

Use evidence from scholarly health literature to support and justify your discussions and interventions. (Intext references are included in the word counts. The reference list is not included in the word count.

Conclusion:

Briefly recount the key concepts discussed in the case study response. Make a strong statement that reiterates the clinical reasoning of your case study response. Avoid repeating the introduction in past tense.

 

Answer:

Introduction

Holistic patient care involves a critical patient assessment to identify the physical, social, emotional, psychological, and biological needs and effects of the interventions. Pharmacotherapy remains to be a significant mode of management used by clinicians in the management of acute and chronic cases. Pregnancy is one of the factors to be considered since some drugs have effects that might cause fetal malformations and other complications (Van Gelder et al., 2019, pp. 93-97) The assignment is based on a 35-year-old female who is living with Asthma and Grave's disease was involved in a motorbike accident 18 months ago sustaining blunt trauma to the head. A compound fracture to the tibia and fibula hence underwent an orthopedic surgery and had been suffering chronic pain though she healed. After three months, the patient suffered symptoms of DVT and pulmonary embolism (PE) and was put on anticoagulants. This incident was followed by tonic-clonic seizures six months later and was prescribed with antiepileptic drugs for traumatic epilepsy. The continued treatment and medical check-ups have exposed her to a feeling of depression, and she is currently pregnant. The case study will also explain the medication administered and nursing interventions.

 

Case pathophysiology

DVT is the formation of a clot in the blood vessels in the legs. The clot formed with time can be dislodged and move to the pulmonary circulation into the pulmonary arteries causing a pulmonary embolism. Vessel breakage in a fracture initiates the clotting process to prevent bleeding. This can lead to the formation of clots inside the blood vessel that is not broken down during wound healing hence the occurrence of DVT. DVT develops due to the immobility of an individual, leading to stasis of blood in the vein due to reduced activity (Patel et al., 2017, pp. 191-200). To promote healing, Jolene is advised to immobilize the limb to facilitate tissue remodeling. The clotting process is initiated by the aggregation of proteins that arises when there is stasis in the veins of the lower limbs. DVT is another cause of persistent limb pain ant the calf region while PE presents with respiratory symptoms.

Jolene had surgery to repair compound tibia-fibula fracture. She underwent an internal reduction surgery and was fitted with pins and plates.  The presence of the foreign materials inside bone tissues and tendons irritates the tissues causing the perceived pain.  For a broken bone to heal, it requires about eight weeks for complete remodeling and requires immobility for the bone density to be restored.  Jolene is working is a farm and movement of the limb before proper healing causes pain in the remodeling sector (Richebé, Capdevila, and Rivat, 2018, pp. 590). An incision is done during surgery, cutting through the flesh to align the bones to facilitate bone repair. Chronic pain perceived is a result of nerve damage hence requires frequent analgesics.

Jolene sustained a direct injury to the head, that might have caused contusion to the brain. She has presented with tonic-clonic seizures concluded to be a sign of post-traumatic epilepsy. It is termed as epilepsy since it occurs weeks after the trauma, and the seizures arise with no provocation. Contusion to the brain leads to axonal shearing and vessel breakage, therefore, leading to activation of an inflammatory response, releasing inflammatory mediators to the site as an immune response (Sharma et al., 2019, pp. 3180). Several action potential firing due to the excitatory cascade created leads to the development of seizures. Ischemia leads to the destruction of brain cells affecting the inhibitory mechanisms and activating the excitatory mechanisms lowering the seizure threshold.

Development of epilepsy affects the functioning of the brain leading to mood changes hence the feeling of depression. Jolene is pregnant, and she is worried about the wellbeing of her baby regarding her current conditions and treatment regime. She has been in pain for the past 18 months after the fracture hence has a psychological impact leading to stress and anxiety (Jesulola, Micalos, and Baguley, 2018, pp. 79-90). She cannot perform her activities on the farm adequately with her partner due to the diagnoses, and she is limited to the social activities she can achieve due to the surgical instructions not to overwork the limb.  The medications come up with adverse effects and restrictions in life that affect daily activities. She has developed depression related to serious diagnoses and frequent hospitalization.

 

Mechanism of action of the medication

The patient is on Atrovent, Ventolin, anti-thyroid drugs, anticoagulants, antiepileptic drugs, analgesics, and antidepressants. Atrovent is an anticholinergic that blocks muscarinic receptors reducing acetylcholine hence leading to bronchodilation. Ventolin provides relief from asthma symptoms of narrowed airways by activation of adrenergic receptors (beta-2) in the lungs causing respiratory muscle relaxation (Sellers, 2017, pp. 30). Anti-thyroid drugs reduce the concentration of T3 and T4 in the body hence relieving symptoms of Grave's disease. They inhibit the thyroid peroxidase enzyme, thus prevent the synthesis of hormones. They also act peripherally on deiodinase D1 to prevent activation of T4 to T3, therefore lowering its functions. 

Anticoagulants are drugs used to prevent the formation of clots inside the blood vessels, and they break existing blood clots.  In the management of DVT and PE, patients are prescribed Warfarin or aspirin. Aspirin is an NSAID that acts on the clotting cascade to prevent the aggregation of proteins by inhibiting the formation of an enzyme, thromboxane (Cadavid, 2017, pp. 261). It is safe to administer in pregnancy hence recommended for Jolene. Warfarin inhibits the vitamin reductase enzyme that activates vitamin K and functions of the proteins S, and C. vitamin k is a significant component in clotting as it amplifies the parts of factor II, VII, XI, and X hence their inhibition prevents the clotting of blood (Rishavy et al., 2018, pp. 2826-2835). Warfarin, however, is not safe to be administered in pregnancy due to its teratogenicity side effects. Anti-thyroid drugs reduce the breakdown of vitamin k hence lower the effects of anticoagulants. Administering the drugs together requires dose adjustment.

Analgesics are prescribed for the management of the pain. Since the patient is in constant pain, she is obliged to get over the counter medication to lower pain perception.  In severe or moderate pain, Opioids are administered since they are strong analgesics. They act centrally on the opiate receptors increasing the pain threshold (Goldenberg et al., 2016, pp. 640-648). Paracetamol is a common analgesic used in pain management and is safe to be administered during pregnancy. It acts centrally on the serotonergic receptors reducing pain perception. It is broken down in the liver to form an active metabolite. Its active metabolite works by inhibiting prostaglandin synthesis by inhibition of a cyclooxygenase-2 enzyme involved in the pathway (Saliba et al., 2017, pp. 246). NSAIDs are analgesics that reduce pain and inflammation and act by inhibiting the synthesis of prostaglandins by inhibition of cyclooxygenase 1 and 2 hence prevent the sensation of pain. They interact with Warfarin increasing the INR and can lead to bleeding complications. They pose a significant risk of miscarriage and fetal abnormalities when administered during pregnancy.  

Antidepressants are drugs prescribed to reduce symptoms of depression, promoting the quality of life. The mechanism of action depends on the drug class used. Tricyclic antidepressants act by lowering the levels of acetylcholine in the brain that reduces the mood and increases the concentration of serotonin and noradrenaline in the postsynaptic membrane, thus relieving depressive symptoms (Arias et al., 2018, pp. 1-10). The monoamine oxidase enzyme facilitates the breakdown of neurotransmitters. Antidepressants inhibit the action of enzymes hence maintaining the neurotransmitter concentration in the brain.  Selective serotonin reuptake inhibitors prevent the uptake of serotonin by binding on the 5HT receptor site. Serotonin reduces anxiety and improves mood when in high concentration. Antidepressants interact with opioids by increasing their breakdown hence lowering their analgesic effects. An imbalance in brain biochemistry causes depression; thus, the mechanism of antidepressants of increasing the levels of neurotransmitters restores chemical balance, therefore, resolving depression (Yoon and Chang, 2019, pp. 5). Some of them are safe while others pose fetal complications; hence consideration required in pregnant women.

Traumatic epilepsy is managed by the administration of antiepileptic drugs that act by lowering the excitatory signals and improve the inhibitory pathways raising seizure threshold. They operate on deferent receptors, including glutamate receptors, sodium and calcium channels, and GABA receptors (Wong et al., 2018, pp. 132-142). The modulation of GABA increases the movement of chloride ions into the cell. A more negative cell is less excitable and reduces action potential initiation to create a seizure. On sodium channels, antiepileptic drugs block the influx of sodium ions that results in the firing of signals by axons. Calcium causes depolarization in cells that make a cell prone to an action potential, which leads to seizures (Nigam et al., 2019, pp. 132-138). Carbamazepine increases the breakdown of Warfarin when administered together, reducing its anticoagulant effects. Antiepileptic drugs block this action. Glutamate is the primary excitatory neurotransmitter; the action of antiepileptic drugs increases its uptake hence reducing cell excitability.

 

Nursing interventions

Patient education is one of the nursing interventions to be employed.  For the medication to work, they need to be taken in correct doses, and one has to be adherent. To relieve anxiety, the nurse should explain the case scenario to the patient, the pathology incurred, and the prognosis. The understanding will alleviate symptoms of depression hence facilitate healing. The nurse, in relation to NMBA standard one, has the role of applying evidence-based practice to promote patient recovery hence educate her on the side effects of drugs.  Anticoagulants can cause bleeding; hence the patient should be informed to seek medical attention (Nagle et al., 2017, pp. 10-11). In the first trimester, morning sickness is expected, and the side effects of drugs also cause nausea and vomiting. The patient should be informed that she might experience severe morning sickness due to the drug side effects. The nurse should educate the patient on the importance of drug adherence. Antiepileptic drugs, when not taken, can lead to the experience of seizures, causing more damage to the brain. Falls from seizures can cause physical injury and affect the wellbeing of the baby.

Due to the different diagnoses, Jolene is being managed by different clinicians. The nurse has a role in ensuring the care provided is collaborated to promote patient healing. Different clinicians prescribe different medications; detailed documentation of the patient history should be done to prevent serious drug interactions. The nurse in relation to professional standards ensures quality and safe intervention hence performs thorough patient assessment during the treatment and acts as the patient advocate in the care hence ensures a smooth transition from one clinician to the next hence achieving holistic patient care (Thompson, Fahs, and Kell, 2016, pp. 381). The nurse should ensure patient ideas are considered in decision making also involve jack in the care of the patient informing him of the importance of social support in healing.

Psychological care is an integral part of managing Jolene. She is depressed, resulting from extensive medical check-ups and treatments. The patient is socially alienated from society due to the illness and can barely perform her hobbies. The nurse should ensure the patient receives psychotherapy where she can express her emotions and feelings that promote change in mood. To relieve chronic pain, the nurse advises the patient on the use of relaxation and breathing techniques (Bleiker et al., 2018, pp. 28-32). Human beings are social beings; hence the nurse needs to encourage Jack to escort her to the psychotherapy sessions providing social support. The nurse has a role in providing follow-up care for the patient. Jolene has DVT, epilepsy, and depression. She is using drugs to manage this condition and lead an everyday life despite the bogy function affected. Most patients tend to miss hospital revisits due to loss of hope; the nurse should account for each patient visit and take a personal initiative to contact her.

 

Conclusion

Drugs offer excellent symptomatic relief in acute and chronic illness.  Jolene suffered DVT, PE, epilepsy, depression after an accident, and she is in pain despite the treatment of the fracture. She has been prescribed anticoagulants, analgesics, antiepileptic drugs, and antidepressants to enable her to lead an everyday life. She is pregnant and requires care and consideration when prescribing medications since most medications in these classes cause fetal malformations and premature birth.  Holistic care is essential to provide integrated care to the patient hence promote recovery. The priority nursing interventions applied include; patient education, psychological care, the collaboration of care, and patient follow-up.

 

References

Arias, H.R., Vázquez-Gómez, E., Hernández-Abrego, A., Gallino, S., Feuerbach, D., Ortells, M.O., Elgoyhen, A.B. and García-Colunga, J., 2018. Tricyclic antidepressants inhibit hippocampal α7* and α9α10 nicotinic acetylcholine receptors by different mechanisms. The international journal of biochemistry & cell biology, 100, pp.1-10. Doi 10.1016/j.biocel.2018.04.017.

Bleiker, J., Knapp, K.M., Morgan-Trimmer, S. and Hopkins, S.J., 2018. "It's what's behind the mask": Psychological diversity in compassionate patient care. Radiography, 24, pp.S28-S32. Doi 10.1016/j.radi.2018.06.004.

Cadavid, A.P., 2017. Aspirin: the mechanism of action revisited in the context of pregnancy complications. Frontiers in immunology, 8, p.261.doi 10.3389/fimmu.2017.00261.

Goldenberg, D.L., Clauw, D.J., Palmer, R.E. and Clair, A.G., 2016, May. Opioid use in fibromyalgia: a cautionary tale. In Mayo Clinic Proceedings (Vol. 91, No. 5, pp. 640-648). Elsevier. Doi 10.1016/j.mayocp.2016.02.002.

Jesulola, E., Micalos, P. and Baguley, IJ, 2018. Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model-are we there yet?. Behavioural brain research, 341, pp.79-90. Doi 10.1016/j.bbr.2017.12.025.

Nagle, C., Heartfield, M., McDonald, S., Morrow, J., Kruger, G., Bryce, J., Birks, M., Cramer, R., Stelfox, S. and Hartney, N., 2017. A necessary practice parameter: Nursing and Midwifery Board of Australia Midwife standards for practice. Women and Birth, 30, pp.10-11. Doi 10.1016/j.wombi.2017.08.028.

Nigam, A., Hargus, N.J., Barker, B.S., Ottolini, M., Hounshell, J.A., Bertram III, E.H., Perez-Reyes, E. and Patel, M.K., 2019. Inhibition of T-Type calcium channels in MEC layer II stellate neurons reduces neuronal hyperexcitability associated with epilepsy. Epilepsy research, 154, pp.132-138. Doi 10.1016/j.eplepsyres.2019.05.006.

Patel, K., Fasanya, A., Yadam, S., Joshi, A.A., Singh, A.C. and DuMont, T., 2017. Pathogenesis and epidemiology of the venous thromboembolic disease. Critical care nursing quarterly, 40(3), pp.191-200. Doi 10.1097/cnq.0000000000000158.

Richebé, P., Capdevila, X. and Rivat, C., 2018. Persistent Postsurgical Pain Pathophysiology and Preventative Pharmacologic. Anesthesiology, 129(3), p.590. doi 10.1097/aln.0000000000002238.

Rishavy, M.A., Hallgren, K.W., Wilson, L., Singh, S., Runge, K.W. and Berkner, K.L., 2018. Warfarin alters vitamin K metabolism: a surprising mechanism of VKORC1 uncoupling necessitates an additional reductase. Blood, The Journal of the American Society of Hematology, 131(25), pp.2826-2835.doi 10.1182/blood-2017-09-804666.

Saliba, S.W., Marcotegui, A.R., Fortwängler, E., Ditrich, J., Perazzo, J.C., Muñoz, E., de Oliveira, A.C.P. and Fiebich, BL, 2017. AM404, paracetamol metabolite, prevents prostaglandin synthesis in activated microglia by inhibiting COX activity. Journal of neuroinflammation, 14(1), p.246. doi 10.1186/s12974-017-1014-3.

Sellers, W.F., 2017. Asthma pressurised metered dose inhaler performance: propellant effect studies in delivery systems. Allergy, Asthma & Clinical Immunology, 13(1), p.30. doi 10.1186/s13223-017-0202-0.

Sharma, R., Leung, W.L., Zamani, A., O'Brien, T.J., Casillas Espinosa, P.M. and Semple, B.D., 2019. Neuroinflammation in Post-Traumatic Epilepsy: Pathophysiology and Tractable Therapeutic Targets. Brain sciences, 9(11), p.318.doi 0.3390/brainsci9110318.

Thompson, C., Fahs, B. and Kell, C., 2016. A nurse-led collaborative linking medical centre with community partners transforms patient care and reduces readmissions. Heart & Lung: The Journal of Acute and Critical Care, 45(4), p.381.doi 10.1016/j.hrtlng.2016.05.026.

Van Gelder, M.M., de Jong, L.A., te Winkel, B., Olyslager, E.J., Vorstenbosch, S., van Puijenbroek, E.P., Verbeek, A.L. and Roeleveld, N., 2019. Assessment of medication use during pregnancy by Web-based questionnaires, pharmacy records and serum screening. Reproductive Toxicology, 84, pp.93-97. Doi 10.1016/j.reprotox.2019.01.002.

Wong, S.Q., Jones, A., Dodd, S., Grimes, D., Barclay, J.W., Marson, A.G., Cunliffe, V.T., Burgoyne, R.D., Sills, G.J. and Morgan, A., 2018. A Caenorhabditis Elegans assay of seizure-like activity optimized for identifying antiepileptic drugs and their mechanisms of action. Journal of neuroscience methods, 309, pp.132-142. Doi 10.1016/j.jneumeth.2018.09.004.

Yoon, S. and Chang, S.M., 2019. Gender Differences in the Clinical Manifestations of Depression and Related Neurotransmitters. J Korean Soc Biol Ther Psychiatry, 25(1), p.5. doi 10.1016/j.eurpsy.2016.01.282.

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