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You are required to prepare 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. Describe the patients presenting problem focusing on the pathophysiological issues.
  2. Review and use of literature to explain the pharmacokinetics of the prescribed medications and their indications.
  3. Discuss the nursing management appropriate for the patient including management of the adverse effects of the medication(s) using evidence-based literature.
  4. Describe in 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?

Mr Ferguson is a 76 year old male who presented to your emergency department at 0800hrs complaining of a 2/24 history of chest heaviness. He has self administered x2 sprays of his glyceryl trinitrate pump spray totaling 800mcg with minimal relief. On arrival to your allocated bed Mr Ferguson appears pale, diaphoretic & short of breath.

Mr Ferguson’s case study

Physiological Processes and Functional Changes

Mr. Ferguson, being 76 years old. He has a heavy chest and presents signs of high blood pressure and his heart rate is abnormal. Ferguson has history of Angina, Non ST Elevated Myocardial Infarction, hypertension, and hypercholesterolemia. He has sprayed x2 sprays of his glyceryl trinitrate pump spray totaling 800mcg for his heavy chest but without help.  Other medications for the condition are aspirin, metoprolol, and rosuvastatin. He is fully conscious with a GCS of 15. This study is a critical discussion paper related to the nursing management of Mr. Ferguson’s addressing; the physiological processes through which the disease progresses and the functional changes resulting from the disease, examines the drugs administered to alleviate the patient’s deteriorating condition by analyzing the functioning of the drugs, the effects and the expected results from the use of the drugs and his nursing care plan.

Mr. Ferguson is experiencing chest heaviness which has resulted in paleness, diaphoresis and shortness of breath. His blood pressure is not within the normal range. Systolic pressure is 172 which indicates hypertension stage two while diastolic pressure is 86 which is within the prehypertensive range.  Hypertension experienced by the patient may be as a result of an angina attack which had experienced in the past (Sanjay & Peter, 2014).His heart rate indicates that he has tachycardia (from his hypertension). The patient’s blood oxygenation level is within the normal range (Craig, 2013). The patient’s respiration rate is above the normal range which is indicative that he is hyperventilating and is a sign of possible greater effects which need monitoring.

As already discussed, Mr. Ferguson admitted to the hospital the medical team caring for Mr. Ferguson varied his medication. The variation was indicative of the physiological changes that had occurred in his body resulting in his ill health. The medication prescribed was intended to reverse the physiological changes that had occurred.

Aspirin 300mg Po

Aspirin is administered orally as the patient is conscious as indicated by his 15/15 rate on the Glasgow coma scale. Administration of aspirin is indicative of the patient’s chest pains which can be relieved by aspirin which is an analgesic drug. It is also indicative of cardiovascular problems which are alleviated by aspirin. (Lippincott nursing center, 2018). It has a half-life of fifteen to twenty minutes after which it breaks down into salicylic acid which remains in ones’ body for six hours (Electronic Medicine Compodium, 2013) (Karen & Terry, 2015). Aspirin works by reducing the action of enzymes in order to inhibit prosaglandins synthesis and, thereby, performing its analgesic function.

Drugs Administered to Alleviate Conditions

Morphine sulphate IV 2.5mg administered on

The use of morphine sulphate indicates pain and respiratory depression which is line with Mr. Ferguson’s chest heaviness and shortness of breath. It is used in relieving pain by Patient Controlled Analgesia (PCA) (Electronic Medicine Compodium, 2013). Morphine is broken down and absorbed mainly in the liver and undergoes fusion with glucuronic acid. The drug acts on the Central Nervous System and smooth muscles. It increases smooth muscle tonus especially pyloric sphincter, anal sphincter, lower esophageal sphincter and ileocecal sphincter. Morphine is a depressant but it may at as a stimulant to certain parts of the CNS resulting in nausea and vomiting. (Stitzlein, Opiods for pain management in older adults, 2017).

Low molecular weight (LMW) heparin infusion

The use of this drug indicates myocardial infarction and the likely hood of blood clots. The drug is administered subcutaneously and is almost completely absorbed. The level of spread of the drug in the body is close to the blood volume. It is partially metabolized by desulphatation and depolymerization. (Sarah & Sandra, 2013). The major side effect is that as an anticoagulant it may hinder clotting hence cuts or surgical operations must be avoided after administration of the drug.

Fentanyl 50mcg IV, x2 STAT doses

Administration of fentanyl indicates that Mr. Ferguson is experiencing some pain which requires relief and is also experiencing respiratory depression. Approximately, the volume of the level of distribution between 60L to over 300L, estimates of terminal half-life range from about 1.5 to 6 hours and total elimination from the body ranges from 0.4 to over 1.5 L/min. Around 10% of the dose is excreted through the kidneys; the rest of the drug would seem to be eliminated mainly through the hepatic with contributions from other tissues. (Stitzlein, Opioids for pain management in older adults: Strategies for safe prescribing, 2017).

Drug interactions

Morphine increased patient exposure to aspirin (Bartko, 2018). This is of great importance to patients as aspirin is imperative in preventing the formation of blood clots hence greater exposure enables the drug to be more effective. The combination of aspirin, morphine, low molecular heparin and fentanyl is common practice in treating cardiovascular diseases. The combination of pain relieving drugs that is aspirin, morphine and fentanyl increases the analgesic effect and reduce the side effects particularly the gastrointestinal problems caused by aspirin (Abate & Buttaro, 2015)

The nursing care plan needs to will focus on subjective and objective data. It will further need to focus on monitoring the patient’s vital signs to bring attention to any impending risks. (Teresa, Sherry, & Nitish, 2018). In Mr. Ferguson’s case, subjective data includes chest pains, shortness of breath, paleness and diaphoresis while objective data includes tachycardia and respiratory depression.

Nursing Care Plan

Nursing Management and Prevention of adverse effects of drugs

Aspirin 300mg Po

Short term use of aspirin results in gastrointestinal discomfort (Baron, et al., 2013). This could further cause nausea, vomiting and the occurrence of ulcers. Management plan here should include counter measures against these or opting for morphine sulphate in the management of pain.

Morphine sulphate IV 2.5mg

Side effects of the drug include nausea, vomiting, difficulty in defecating, dizziness, drowsiness or diaphoresis. Most of the side effects subside with time. However, to prevent constipation patients ought to modify their diet to include foods high in fiber and water. A laxative may also be prescribed (Drug guideline: morphine, 2014).

Low molecular weight (LMW) heparin infusion

The major side effect of the drug is uncontrolled bleeding. Nurses must educate the patient on the risk of uncontrolled bleeding. They should further monitor the patient. This includes measurements of coagulations, such as activated partial thromboplastin time, whole blood clotting time, activated clotting time and a complete blood count (CBC) to monitor platelets and assess for bleeding. (Abby, et al., 2016).

Fentanyl 50mcg IV, x2 STAT doses

Common side effects of the drug include difficulty in defecation, respiratory depression, vertigo and fatigue (Kenn, Gayle, & Elizabeth, 2015).

a. Administration of aspirin.

b. If it fails to relieve pain then this is followed up with morphine sulphate.

c. Cardiac monitoring.

d. This may be through a administering an electrocardiography test to the patient to monitor the patient’s condition so as to inhibit deteriorating of the patient’s condition such as cardiac arrest.

e. Monitoring of the blood pressure

f. Administration of heparin to prevent blood clotting which is likely.

g. Monitor cardiac enzymes.

The aforementioned nursing interventions like administration of aspirin, and having a backup (morphine sulphate) incase aspirin fails is a wise management plan that can help effectively relieve Mr. Ferguson’s pain. Other interventions that have been mentioned have minimal effects on Mr. Ferguson and hence effective. On the management of the negative effects of the drugs used, it is good to consider whether they outweigh the positive effects. For example, research undertaken specifically in older age groups have shown in both acute and chronic users of aspirin, that infrequent use of a proton pump inhibitor (PPI) brings down the likelihood of occurrence of gastrointestinal bleeding and chances of contracting of peptic ulcer disease. (Mechcatie & Rosenberg, 2018). Morphine use can cause constipation but the management plan for Mr. Ferguson includes caution against that. Low molecular weight (LMW) heparin infusion may be more risky considering the age of the patient (76).  Advanced age is a vulnerability for morality (Gavrilov, Gavrilova, & Krut'ko, 2017) and in case there is uncontrolled blood loss then Mr. Ferguson will be predisposed to a much more risk of death. The side effects of Fentanyl like fatigue and constipation are not as serious and can be easily managed (Kenn, Gayle, & Elizabeth, 2015).

Prevention of Adverse Drug Effects

The emergency department nurse needs to explain to the patient the changes in the medication and the reason for the change of each medication. Of greater importance is the need to explain to the patient the side effects of each of the drugs and the necessary steps to counter the more disconcerting side effects. The patient should be comprehensively advised on the adverse effects of the medications especially when the dosages are not adhered to. Educating on the need for lower-does prescribing is important as that reduces the side effects of pharmaceuticals (Daughton & SueRuhoy, 2013). The long term effects of drug use, for example aspirin and its fatal risk of gastrointestinal bleeding, should be emphasized and ways to manage them like seeking prompt medical intervention (Huang, Strate, Ho, Lee, & Chan, 2011).

Conclusion

Health management in the emergency department requires proper knowledge of patient history as well as ability to detect the pathophysiological issues facing the patient. All drugs administered to the patient need to be well explained to them and all side effects within manageable bounds should be managed so as to ensure patient ability to follow through with treatment. It is a common practice to prescribe an array of medication to be administered together particularly analgesic drugs as the interaction of these drugs is harmless if patients adhere to the prescribed doses. Any side effects should be explained by the health practitioner to the patient and any side effects out of the ordinary ought to be communicated to the nurse.

References

Abate, K., & Buttaro, T. (2015). Safe and effective NSAID use. The nurse practitioner.

Abby, B., Matthew, B., John, C., Kari, H., Amy, S., & Stephanie, J. (2016). A review on the reversal of the old and new anticoagulants. Advanced emergency nursing.

Baron, Senn, S., Voelker, M., Lanas, A., Laurora, I., W., T., . . . McCarthy, D. (2013). Gastrointestinal Adverse Effects of Short-Term Aspirin Use: A Meta-Analysis of Published Randomized Controlled Trials. Drugs in R and D.

Bartko, J. (2018). Morphine Interaction with Aspirin: a Double-Blind, Crossover Trial in Healthy Volunteers. The journal of pharmacology and experimental therapeutics, 430-436. doi:10.1124/jpet.117.247213

Craig, K. (2013). Monomorphic ventricula tachycardia. Nursing.

Daughton, C. G., & SueRuhoy, I. (2013). Lower-dose prescribing: Minimizing “side effects” of pharmaceuticals on society and the environment. Science of The Total Environment, 443, 324-337. doi:10.1016/j.scitotenv.2012.10.092

(2014). Drug guideline: morphine. Liverpool: south western sydney health district.

Electronic Medicine Compodium. (2013, 06 115). Aspirin Tablets BP 300mg (POM) - Summary of Product Characteristics (SmPC) - (eMC). . Retrieved October 20, 2018, from Electronic Medicine Compodium: https://www.medicines.org.uk/emc/product/5712

Gavrilov, L. A., Gavrilova, N. S., & Krut'ko, V. N. (2017). Historical Evolution of Old-Age Mortality and New Approaches to Mortality Forecasting. Living 100 Monogr. Retrieved 10 30, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5696801/

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. doi: 10.1016/j.amjmed.2010.12.022

Karen, A., & Terry, B. (2015). Safe and effective NSAID use. The nurse practitioner.

Kenn, K., Gayle, M., & Elizabeth, S. (2015). Pain assessment and management in older adults. Critical care nursing quaterly.

Lippincott nursing center. (2018). Nursing pocket card; Myocardial infarction. Retrieved from Lippincott Nursing Center: https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/myocardial-infarction

Mechcatie, E. M., & Rosenberg, K. (2018). A One-Dose-Fits-All Approach to Aspirin Therapy is Suboptimal. American journal of nursing, 69-70.

Sanjay, K., & Peter, B. (2014). Selected abstracts from recent publications in cardiopulmonary disease prevention and rehabilitation. Journal of cardiopulmonary rehabilitation and prevention.

Sarah, G., & Sandra, M. (2013). What NPs need to know aboutanticoagulation therapy. The nurse practitioner.

Stitzlein, D. P. (2017). Opiods for pain management in older adults. The nurse practitioner, 42(2), 20-26. Retrieved 10 25, 2018, from https://www.nursingcenter.com/cearticle?an=00006205-201702000-00006&Journal_ID=54012&Issue_ID=3953291

Stitzlein, D. P. (2017). Opioids for pain management in older adults: Strategies for safe prescribing. The nurse practitioner.

Teresa, T., Sherry, B., & Nitish, P. (2018). Organizational, regional and community factors determining protocal compliance for patients wit acute myocardial infarction. Journal of nursing care quality.

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