Assignment: Fred, a 79-year-old male, is having trouble sleeping, and his son tells him of a drug called Ativan that has helped him sleep.
Assignment: Fred, a 79-year-old male, is having trouble sleeping, and his son tells him of a drug called Ativan that has helped him sleep.
Question 1
Geriatric Case
Fred, a 79-year-old male, is having trouble sleeping, and his son tells him of a drug called Ativan that has helped him sleep. Fred wants to know if Ativan is a good option for his sleep disorder. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Can Ativan be a safe and efficacious treatment option? Explain your rationale.
Based on the guidelines in the topic Resources, what is a strong non-pharmacologic approach for the treatment of insomnia? Include the components of therapy. (150 words and 1 citation within the last five years)
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Pregnancy Case
Kim is a 29-year-old pregnant female in her last trimester. She is suffering from a urinary tract infection. For urinary tract infections prior to being pregnant, she has been prescribed nitrofurantoin. She currently has leftover pills from her last prescription. Kim would like to know if it is okay to use this to start treatment. Use the guidelines and relevant literature in your topic Resources to discuss the following:
What is the Pregnancy Category of nitrofurantoin?
Can nitrofurantoin be a safe and efficacious treatment option? Explain your rationale.
Based on the committee’s opinion on the topic of Resources, what do you recommend as a safer alternative? Be sure to include the dose, frequency, and duration with your recommendation. (100 words and 1 citation within the last five years)
Question 2
Muscarinic Antagonist
Ted, a 77-year-old male, is experiencing an increased sense of urination. It has been interfering with his sleep. He mentions he is urinating on average 8 times in a 24-hour period. The patient was recommended oxybutynin as a treatment option. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Briefly describe the pathophysiology of overactive bladder.
Briefly discuss how the anti-muscarinic therapy can be used in the treatment of overactive bladder.
Using the AUA and SUFU guidelines in the topic Resources, develop a treatment plan to include non-pharmacologic and pharmacologic approaches. Be sure to include drug, dose, frequency, monitoring parameters, and counseling points in your plan.
In the event the patient is presented with narrow-angle glaucoma or gastric-emptying issues, what issues are associated with anti-muscarinic therapy? (100 words and 1 citation within the last five years)
2 Muscarinic Agonist
Martha, an 80-year-old female, has been prescribed pilocarpine as part of her glaucoma treatment. She noticed the bottle of pilocarpine drops was on the floor near her cat, Felix. Martha is very worried that her cat may have ingested the medication. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Briefly describe the pathophysiology of open-angle glaucoma.
Briefly discuss how a muscarinic antagonist can be used in the treatment of glaucoma.
In the event Felix ingested the medication, what sympathetic and parasympathetic effects may be experienced?
Identify which medications are considered first-line for treating open-angle glaucoma. Compare the first-line medications to pilocarpine in regard to efficacy, mechanism of action, and side effect profile. (150 words and 1 citation within the last five years)
Question 3
Case 1 Adrenergic Antagonist
Deb is a 32-year-old female who struggles to maintain her blood pressure. Deb is currently using lifestyle modifications to decrease her blood pressure. She is not interested in taking antihypertensives. Upon completing her medication reconciliation, you determine she consistently uses pseudoephedrine for nasal congestion. You suspect this pseudoephedrine is contributing to the patient’s hypertension. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Based on the JNC-8 guidelines in the topic Resources, list the various blood pressure goals. Include when pharmacologic intervention is needed.
Describe the non-pharmacologic approach (lifestyle modifications) to treat hypertension.
Based on the mechanism of action of pseudoephedrine, describe how this can contribute to Deb’s hypertension and congestion relief.
Compare and contrast the difference between phenylephrine and pseudoephedrine. Include modes of action, efficacy, and other relevant information in your response.
What may be an alternative to adrenergic agonist when treating congestion in hypertension? Explain your rationale. (100 words and 1 citation within the last five years)
Case 2 Adrenergic Agonist
Daniel, a 23-year-old male, is nervous about performing at his concert tonight. His friend offers him propranolol as a treatment because it is considered relatively safe. More than 2 days a week but not daily, Daniel suffers from asthma symptoms that require an inhaler. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Based on the asthma guidelines, how would you categorize Daniel’s asthma?
Summarize the diagnostic criteria associated with social anxiety disorder.
Describe the mechanism of action of propranolol and how it differs from metoprolol.
Compare and contrast the difference in propranolol and albuterol’s effect on the lungs.
Explain your rationale for discouraging the use of propranolol in this patient (e.g., pathophysiology and guideline recommendations). (150 words and 1 citation within the last five years)
Question 4
Steve, a 19-year-old male college basketball player, fell during practice. He is now complaining of leg pain. His trainer recommends a combination of rest, acetaminophen, and ibuprofen for pain control. Use the guidelines and relevant literature in your topic Resources to discuss the following:
How does acetaminophen treat pain? Include pathophysiology and mechanism of action and determine if it treats the perception of pain or the site of trauma.
Describe how ibuprofen treats pain. Be sure to include the pathophysiology and mechanism of action and determine if it treats the perception of pain or the site of trauma.
Explain your rationale for combining the two medications for the treatment of Steve’s pain.
Develop a plan for treating Steve’s pain, including non-pharmacologic and pharmacologic approaches, including monitoring parameters and relevant counseling points. (200 words and 1 citation within the last five years)
Question 5
Samantha, a very healthy 67-year-old female, is undergoing a total hip arthroplasty surgery. The surgeon has asked for a pain regimen for Samantha’s stay on Med-Surg. The plan is for Samantha to be discharged from the hospital on post-op day 1. She currently takes 5mg of hydrocodone daily at home on a consistent basis. The hospital formulary consists of the following medications: oxycodone 5mg, morphine IV 2mg, ketorolac IV 30mg, pregabalin 75mg, gabapentin 300mg, dexamethasone IV 10mg, acetaminophen 500mg, and celecoxib 200mg. Use the guidelines and relevant literature in your topic Resources to discuss the following:
Briefly explain the concept of milligram morphine equivalent (MME).
Discuss Samantha’s MME based on her home medication use.
Develop a plan for post-op day 0 and post-op day 1, using a multi-modal pain approach. Keep in mind the patient is to be discharged on post-op day 1 after the completion of physical therapy.
Explain your rationale for the use of each individual medication. Consider pharmacokinetic aspects related to onset, peak, and duration. Specify which medications are scheduled and which are to be given as needed. Include monitoring parameters and other relevant information for the nursing staff administering the medications (e.g., CAM, used in managing central nervous system, pain, inflammation, and bone or joint disorders). (200 words and 1 citation within the last five years)
Advanced Pharmacology
Question 1
Geriatric Case
Ativan is not a safe and efficacious treatment option for insomnia in this client’s case. Ativan has been shown to be effective for sleep initiation and sleep continuity. However, it is only used for short periods of treatments preferably not more than seven days. Ativan is associated with adverse effects such as headache, drowsiness, ataxia, dizziness, nausea, rebound amnesia, nervousness, psychological dependence, anxiety, and anterograde amnesia. Chronic use of Ativan may also predispose the patient to trauma, pressure ulcers, and pneumonia. As a result, Ativan is not the drug of choice for this patient because of its associated safety concern. Issues such as falls and cognitive decline will increase the risk of poor quality of life for the elderly patient (Flaxer et al., 2021). The strong non-pharmacologic approach of treating insomnia is brief behavioral therapy. A nurse can deliver brief behavioral therapy in two sessions to help the patient developing effective skills to improve sleep quality and quantity (Molnar et al., 2021).
Pregnancy Case
The Food and Drug Association (FDA) considers nitrofurantoin a category B drug. Nitrofuntaoin is classified into category B drugs because studies have not shown any obvious harm to the fetus with its exposure. Nitrofurantoin may be safe and efficacious treatment option. However, it can affect the activity of glutathione reductase causing hemolytic anemia. Some studies have associated the use of nitrofurantoin in pregnancy with neonatal jaundice. There is also the evidence that links nitrofurantoine use to craniosynostosis (Temple & Dresang, 2023). Based on the committee’s opinion and evidence-based data, I would recommend the use of oral Cefuroxime 250 mg BD for five days, as it is a safer option.
Question 2
Muscarinic Antagonist
Overactive bladder is a condition characterized by nocturia, urgency, and frequency, with or without incontinence. The development of overactive bladder is attributed to any factor that disturbs myogenic, urotheliogenic, and neurogenic processes of the bladder. Age-related diseases in the elderly such as neurogenic and degenerative disease may also alter the normal functioning of the bladder, leading to the development of overactive bladder syndrome (Gamé & Phé, 2020). Anti-muscarinic therapy can be used to treat overactive bladder. Anti-muscarinic medicines normalize the functioning of the balder without interfering with the parasympathetic regulation of other body organs. The patient’s treatment plan includes oral oxybutynin 5 mg once daily. The monitoring parameters include oxybutynin adverse effects such as urinary retention, vision changes, constipation, and dehydration. The patient should be educated about the side and adverse effects of the drug, treatment adherence, and avoiding over-the counter medications (Vozmediano-Chicharro et al., 2020). The recommended non-pharmacological interventions include pelvic floor muscle exercises, scheduled toilet visits, bladder training, and maintaining a healthy weight.
Anti-muscarinic medications hinder the parasympathetic nerve impulses through their blocking of acetylcholine to their receptors. The inhibition results in the development of glaucoma in individuals with a history of narrow angle glaucoma. Anti-muscarinic medications are also contraindicated in individuals with gastric-emptying problems. The medications decrease gastric emptying and gut motility by inhibiting parasympathetic nervous system (Kachru et al., 2021).
Muscarinic Agonist
Open-angle glaucoma is a chronic, irreversible, and progressive neuropathy of the optic nerve. It is associated with open angle of the anterior chamber, changes in the optic nerve head, and progressive loss of peripheral vision followed by central visual field loss. There is decreased drainage of aqueous humor in the trabecular meshwork, leading to increased intraocular pressure (Mahabadi et al., 2023). Muscarinic agonist increases aqueous outflow by stimulating the contraction of the ciliary muscle. This decreases intraocular pressure and protects optic nerve and retinal damage. The parasympathetic effects expected if Felix ingested pilocarpine include increased sweating, salivation, production of tears, motility of the smooth muscles of the gastrointestinal, respiratory, and ocular system. The drug will inhibit fight and flight mechanisms of the sympathetic nervous system, hence decreased arousal and response to stimuli. Prostaglandin analogues such as latanaprost are considered the first-line drugs of choice in open-angle glaucoma. The analogues work by binging to FP and EP receptors of the ciliary muscles, causing relaxation and increased outflow of the aqueous humor (Joh & Jin, 2019). They have limited local side effects, high efficacy, but expensive and difficult to find as compared to pilocarpine.
Question 3
Adrenergic Antagonist
The blood pressure goals in JNC 8 are varied. They include initiating pharmacologic treatments to lower systolic blood pressure to less than 150 mm Hg or diastolic less than 90 mm Hg in general population, 140/90 in all persons aged below 60 years and above 18 years with diabetes or chronic kidney disease. It also recommends the use of thiazide diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, or angiotensin 2 receptor blockers in the treatment (Kovell et al., 2015). The non-pharmacological interventions to treat hypertension include weight management, reducing salt intake in diet, engaging in active physical activities, avoiding diets rich in saturated fats, and avoiding alcohol and smoking (Verma et al., 2021). Pseudoephedrine acts on both alpha-1 and beta receptors to cause symptoms such as tachycardia, anxiety, agitation, tremors, and hypertension, hence, Deb’s complaints. Phenylephrine and pseudoephedrine are used for nasal congestion. However, phenylephrine is less efficacious as compared to pseudoephedrine but the former has more side and adverse effects as compared to pseudoephedrine. Phenylephrine is an appropriate alternative to pseudoephedrine, which helps ease nasal congestion with minimal cardiac effects (Dean II & Reddivari, 2023).
Adrenergic Agonist
Daniel has mild persistent asthma because symptoms occur more than two times a week but not daily. The diagnostic criteria associated with social anxiety disorder as per DSM5 include persistent and intense fear or anxiety about social situations, avoidance of social situations that produce anxiety, excessive anxiety out of proportion to the situation, and anxiety that interferes with daily living. The anxiety is not attributed to a medical condition, substance abuse, or medication use. Propranolol is a non-selective antagonist of beta receptors while metoprolol is a selective beta-1 adrenergic receptor antagonist. The difference in effect on the lungs is that propranolol blocks beta-2 receptors while metoprolol blocks only beta-1 receptors (Morris & Dunham, 2023). I would discourage the use of propranolol in this patient because it would non-selectively block-2 adrenergic receptors in the lungs, leading to worse asthma symptoms.
Question 4
Acetaminophen works by inhibiting cyclooxygenase pathways to produce its analgesic and antipyretic actions. Acetaminophen affects perception of pain by inhibiting cyclooxygenase pathway in the central nervous system and not on the site of injury. Ibuprofen is a drug used in treating pain. Ibuprofen works by non-selectively inhibiting cyclooxygenase enxymes COX1 and COX-2. The inhibition results in the blocked production of prostanoid-prostaglandins and thromboxane, which modulate and activate pain. Ibuprofen treats pain perception and pain at the site of trauma. For example, besides central nervous inhibition of pain, it also lowers the threshold of nociceptor neurons to pain and limit edema formation at the site of injury by blocking pro-inflammatory prostaglandins (Varrassi et al., 2020). Acetaminophen and ibuprofen were combined in treating Steve’s pain because they provide superior pain relief than using one of the drugs alone.
The plan for treating Steve’s pain includes administering Maxigesic one tablet every six hours. I would educate him about the importance of treatment adherence, avoiding over-the-counter medications, and anticipated side effects. I would also monitor him from side effects such as development of peptic ulcers and easy bruising, which would indicate adverse effects (Varrassi et al., 2020). I would educate him on the use of non-pharmacological interventions such as rest, cold compresses, and minimal activity on the affected limb.
Question 5
Morphine milligram equivalents (MME) refer to the values that represent an opioid dose potency that is relative to that of morphine. MME helps clinicians to develop appropriate treatment decisions on the opioid regimens for their patients. Samantha’s MME based on her home medication use include 7.5MMEs for oxycodone, 2MMEs for morphine, and 75MMEs for acetaminophen. Multimodal analgesia refers to an approach of pain management that combines the different medication groups for pain relief. The most effective multimodal analgesia for the patient will combine acetaminophen 500 mg four six hourly, morphine IV 2 mg for pain as needed, oxycodone 5 mg 5 mg four hourly, and Gabapentin 300 mg three times daily.
Acetaminophen is an effective analgesic and antipyretic. It would treat perception of pain by inhibiting cyclooxygenase pathways. Morphine and oxycodone are potent opioids for pain management. Morphine will be administered as needed for pain while oxycodone will be used for maintaining pain relief. Gabapentin will be appropriate to manage pain resulting from nerve damage (Chen et al., 2021). The monitoring parameters for these medications will include patient’s perceived pain rating in a pain rating scale, side effects experienced, and adverse effects that may be reported.
References
Chen, Y.-Y. K., Boden, K. A., & Schreiber, K. L. (2021). The role of regional anaesthesia and multimodal analgesia in the prevention of chronic postoperative pain: A narrative review. Anaesthesia, 76(S1), 8–17. https://doi.org/10.1111/anae.15256
Dean II, J. S., & Reddivari, A. K. R. (2023). Alpha-1 Receptor Agonists. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK551698/
Flaxer, J. M., Heyer, A., & Francois, D. (2021). Evidenced-Based Review and Evaluation of Clinical Significance: Nonpharmacological and Pharmacological Treatment of Insomnia in the Elderly. The American Journal of Geriatric Psychiatry, 29(6), 585–603. https://doi.org/10.1016/j.jagp.2020.10.011
Gamé, X., & Phé, V. (2020). [Pathophysiology of overactive bladder]. Progres en urologie, 30(14), 873–879. https://doi.org/10.1016/j.purol.2020.08.003
Joh, H. J., & Jin, S. W. (2019). Comparison of different combinations of maximum medical therapy for lowering intraocular pressure in primary open angle glaucoma: 12-month retrospective consecutive case series. Japanese Journal of Ophthalmology, 63(4), 322–327. https://doi.org/10.1007/s10384-019-00673-8
Kachru, N., Holmes, H. M., Johnson, M. L., Chen, H., & Aparasu, R. R. (2021). Antimuscarinic use among older adults with dementia and overactive bladder: A Medicare beneficiaries study. Current Medical Research and Opinion, 37(8), 1303–1313. https://doi.org/10.1080/03007995.2021.1920899
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Mahabadi, N., Foris, L. A., & Tripathy, K. (2023). Open Angle Glaucoma. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK441887/
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Morris, J., & Dunham, A. (2023). Metoprolol. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK532923/
Temple, J., & Dresang, L. (2023). Is nitrofurantoin use in the first trimester associated with congenital malformations? Evidence-Based Practice, 26(7), 1. https://doi.org/10.1097/EBP.0000000000001843
Varrassi, G., Pergolizzi, J. V., Dowling, P., & Paladini, A. (2020). Ibuprofen Safety at the Golden Anniversary: Are all NSAIDs the Same? A Narrative Review. Advances in Therapy, 37(1), 61–82. https://doi.org/10.1007/s12325-019-01144-9
Verma, N., Rastogi, S., Chia, Y., Siddique, S., Turana, Y., Cheng, H., Sogunuru, G. P., Tay, J. C., Teo, B. W., Wang, T., TSOI, K. K. F., & Kario, K. (2021). Non‐pharmacological management of hypertension. The Journal of Clinical Hypertension, 23(7), 1275–1283. https://doi.org/10.1111/jch.14236
Vozmediano-Chicharro, R., Blasco Hernández, P., & Madurga-Patuel, B. (2020). Insights into the Management of Overactive Bladder with Transdermal Oxybutynin: A Practical Review. Research and Reports in Urology, 12, 321–330. https://doi.org/10.2147/RRU.S266400
