Group #13
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School
Wayne State University *
*We aren’t endorsed by this school
Course
NUR 5800
Subject
Medicine
Date
Jan 9, 2024
Type
Pages
5
Uploaded by MateScienceGuineaPig16
Atterbury, Mackenzie
Jonas, Brittany
Lee, Yeo
A 36 y/o female patient is hospitalized for a DVT. Home meds include birth control pills. She has no
significant past medical history. She is a smoker. She has received 5 days of IV heparin therapy and will
require 3 more months of anticoagulation therapy to prevent the DVT from recurring. The physician
writes an order to discontinue the heparin now & begin warfarin 5mg orally daily starting today.
1.
This is a mistake that sometimes occurs with anticoagulation therapy. This is NOT the
appropriate way to switch a patient from heparin to warfarin. Think about the mechanism of
action, onset of action & half-life of these anticoagulants and explain why this is not optimal.
How would you recommend switching her over to warfarin? Discuss appropriate dosing &
monitoring in general terms.
We recommend the patient remain on warfarin but begin heparin to prevent a recurrent DVT.
This will
allow the Warfarin to reach a therapeutic level due to its long duration of onset of
action.
2.
2. Why did such a young woman develop a blood clot? What were her risk factors?
She most likely developed a blood clot due to the estrogen in her birth control pills. She had a
risk
factor of being a smoker.
3.
List the key patient education topics that you should tell this patient regarding warfarin therapy.
Take Warfarin at the same time each day, do not skip doses, do not over eat foods rich in
vitamin
K, watch for signs and symptoms of bleeding or blood clots.
4.
4. While providing warfarin education, she asks several questions. How would you answer each
question?
a.
Warfarin has been used in other ways, but Warfarin is also approved for medical use to
treat your condition. There are many great advantages to taking this medication. We
feel the benefits are in your best interest.
b.
All medications carry risks and should be used with discretion. If used properly and with
proper monitoring the medication is expected to work as expected. Be sure to use the
medication as directed for maximal advantage.
5.
Three days after she left the hospital, an INR was drawn, and the result was 3.5. What would be
the appropriate action as far as the dose of warfarin?
We recommend modification of dosage and further patient education for following guidelines.
We also
recommended the patient be closely monitored. Follow up with a 48-72 hour redraw of the INR for
reassesment.
6.
The patient calls the office a couple of weeks later and said that she saw an advertisement on
television about a new drug that is an alternative for warfarin called Xarelto (rivaroxaban). List
one advantage of rivaroxaban vs warfarin and list one disadvantage.
An advantage of rivaroxaban would be it does not require monitoring. A disadvantage would be without
routine checkups it may be harder to assess patient and therefore encourage
noncompliance.
Rivaroxaban also has a slower onset than warfarin.
A 63 y/o man comes to the office for a routine dental procedure. He has a past medical history of
myocardial infarction 2 years ago. From his record you see he also has angina and states a recent
coronary angiogram revealed a 30% narrowing of one of his coronary arteries. He gets fairly nervous
during his dental appointments. He tells you that he can usually walk to the newsstand (6 blocks away)
and climb the stairs from his basement without difficulty but lately he has been having CP (chest pain)
after climbing the stairs and he must rest after walking two blocks and take SL NTG to relieve CP. He
states that he has needed to use 3
–
4 SL NTG tablets daily for the last week due to recurrent CP.
1.
Name 3 classes of medications that can be used to treat this patient’s type of angina. Also
describe their mechanism of action and 2 common side effects for each.
-Beta-Blockers
Mechanism of Action: decrease heart rate and force of contraction
Side Effects: hypotension and hypoglycemia due to diabetes
-Calcium Channel Blockers
Mechanism of Action: inhibit calcium from entering the smooth muscle of heart vessel.
Side Effects: dizziness and fatigue
-Nitrates
Mechanism of Action: vasodilators
Side Effects: headache and lightheadedness
2.
During the cleaning he begins to have chest pain. Why is this happening?
The patient was nervous prior to the procedure and the stress may be increasing his heart rate
and
causing chest pain.
3.
Describe the patient instructions for SL NTG
Dissolve one tablet under tongue, do not swallow tablet. If pain is not relieved within 5 minutes,
call 911 or report to the emergency room.
4.
Patient complains of burning with the SL NTG. Can he swallow the pill instead?
The medication is sublingual and must be dissolved under the tongue for the best result.
5.
The patient visits his cardiologist to discuss his frequent chest pain. The cardiologist decides to
put him on a medication to help prevent the chest pain. What class of medication used to
prevent angina pain may be a concern due to his other disease states?
Nitroglycerin belongs to the nitrate class. It may interact with Metformin due to the
kidney
disease.
6.
The cardiologist also instructed him to take one baby aspirin daily. The patient said that this was
silly because one baby aspirin will not do much to relieve his chest pain. How should the
cardiologist respond?
The baby aspirin will help thin the patient's blood and therefore prevent chest pain. The
benefits are greater than it may seem because the dose is low, but it is still going to be
effective.
80 y/o female with a previous MI, CAD, and angina. She was found by her home health aid in her living
room, slumped over in a chair. She is now hospitalized with right-sided paralysis. Heparin is started in
the hospital to allow the body time to dissolve the clot and to prevent a 2nd clot. The rest of her home
medications are continued in the hospital.
1.
Explain the use of each of her medications.
Donepezil treats her symptoms of dementia. Amlodipine lowers her blood pressure. Losartan
treats
heart failure, blood pressure and protects kidneys from damage. Carvedilol treats her HTN
and
heart failure. The nitroglycerin treats her chest pain.
2.
What risk factors did she have for developing a stroke?
MI, CAD, angina.
3.
Discuss how a stroke could have been prevented in this patient?
The patient could have been prescribed warfarin.
4.
List the drug class and two common SE for each antihypertensive. Focus on the common side
effects discussed in class and those that need to be discussed with the patient.
-
Amlodipine: Calcium Channel Blocker. Side Effects: reflex tachycardia and constipation
-Losartan: Angiotensin-2 receptor Blocker. Side Effects: hyperkalemia, hypotension
-Donepezil: Cholinesterase Inhibitor. Side Effects: headache and diarrhea
-Carvedilol: Beta-Blocker. Side Effects: sexual impairment and hypotension
-Nitroglycerin: nitrates. Side effects: venous pooling and headache.
5.
What neurotransmitter does donepezil increase?
Acetylcholine.
6.
Which of her medications would you advise her to not stop abruptly?
Carvedilol.
A 55 y/o female with a history of difficult to control hypertension presents to the ER.
She monitors her
blood pressure at home daily and reports that it has been “just fine” over the last
few months.
The
patientcomplains of a persisting headache that began about 8:30am, has continued all day, and slightly
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diminishes with rest.
She states that when she is supine her head hurts worse and denies any other
illness or discomfort.
Her initial vital signs are BP=188/94, P=86 & regular, RR=16.
1.
Classify each of her antihypertensive in to therapeutic class.
-Clonidine: Alpha-2 agonist.
- Metoprolol: Cardio selective Beta-1 blocker.
- Nifedipine: Calcium Channel Blocker.
- Hydrochlorothiazide: Diuretics.
2.
Labs were drawn and her serum potassium was low.
a.
Hydrochlorothiazide.
b.
Tomatoes, spinach, bananas.
3.
Which of her antihypertensives is most likely to cause bradycardia?
Metoprolol.
4.
Which of her antihypertensives are most likely to cause reflex tachycardia
Nifedipine.
5.
The patient is complaining that she takes too many pills. Offer some suggestions to help.
The patient can increase K+ intake to avoid the supplement. clonidine is also offered as a
transdermal patch.
A 75 year ol
d woman with heart failure is seen at her cardiologist’s office for routine follow
-up. In
addition to heart failure, she has a medical history significant for dyslipidemia, hypertension, and
osteoporosis. She has daily heart failure symptoms of shortness of breath and fatigue particularly when
she is active. Her symptoms have not improved despite adequate therapy with beta-blockers, ACE
inhibitors, and diuretics. In the last year, she has been hospitalized once for exacerbation of her heart
failure.
1.
What are some common causes of heart failure?
Angina, CAD, MI, hypertension.
2.
Which of her medications have the potential to cause HYPERkalemia?
Lisinopril.
3.
The cardiologist decides to put her on digoxin. List the signs and symptoms of digoxin toxicities
Fatigue, weakness, dizziness, headache, confusion, delirium, Blurred vision, haloes, yellow/green
tint vision, cardiac arrhythmia.
4.
What is the treatment of digoxin toxicity?
Increase potassium by using supplements, Treat any arrhythmias with the appropriate
antidysrhythmic, digoxin immune fab.
5.
Using Clinical Pharmacology as a reference:
a.
Cholesterol.
b.
Grapefruit juice increases the level of simvastatin in your blood in large quantities.
6.
The patient complains to her cardiologist that she has a dry hacky cough and wants some cough
syrup. Which of her medications can cause the cough? How could her medications be changed
to help avoid the cough?
Removing lisinopril from medication list should resolve the dry hacky cough and eliminate need for
cough medication.