Asha Peeples

Pharmacology Case Study #1

Vocabulary: Define each of the terms

Age related macular degeneration: Condition in elderly that can cause loss of vision in the macula because of damage to the retina

Bone metastases: Class of cancer metastases that result from a primary tumor

Fall precautions:

Gout: Systemic disease where uric acid deposit in joints and cause inflammation

Multiple myeloma: Malignant spreading of cancerous of plasma cells within the bone

Myelodysplastic syndromes: Group of diseases that affect the bone marrow and blood

Neutropenia: Abnormally low number of neutrophils (white blood cells)

Palmar-plantar erythrodysesthesia: Side effect of some chemotherapy drugs that cause redness, swelling and pain on palm of the hands and/or soles of feet. It is also called hand-foot syndrome

Pathological fractures: Weakness of the bone that caused the bone to break

Secondary hypertension: Also called essential hypertension is caused by identifiable secondary factors such as tumors, endocrine diseases, etc…

Stage pressure ulcer: Observable reddened area of the skin over bony prominences that are not relieved by reducing pressure.

Thrombocytopenia: Abnormally low platelet count

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Situation: A 68-year-old male is admitted from the emergency department after falling at home. He state that he has been fatigues and has severe pain in his pelvic area and back. He was unable to button his shirt or walk normally before the fall, and now he has increased pain and burning in his hands and feet. He wants to stop all this medication.

Home Medications: Use a drug book that contains drug action and kinetics. What is the recommended dose of, route for and best time of day to give these medication. What lab results are needed for each medication? What are the most common diseases treated by medication?

Medication Drug Action Kinetics Dose Route Time Lab Used to TreatAllopurinol Inhibits the

production of uric acid by inhibiting the action of xanthine oxidase

Well absorbed (80%) following oral administration.Widely distributed in tissue

Initially--100 mg/day; increase at weekly intervals based on serum uric acid (not to exceed 800 mg/day).

PO, IV May be administered after milk or meals to minimize gastric irritation; give with plenty of fluid

Serum and urine uric acid levelsMonitor hematologic, renal, and liver function tests

Gout

Clopidogrel Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet

Well absorbed following oral administration; rapidly metabolized to an active antiplatelet compound.Rapidly and extensively

75 mg once daily

PO Administer once daily without regard to food.

Monitor bleeding time during therapy.Monitor CBC with differential and platelet count periodically during therapy. Neutropenia and thrombocytopenia

MI, strokes, PVD

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receptors. converted by the liver to its active metabolite, which is then eliminated 50% in urine and 45% in feces.

may rarely occur.

Dexamethasone Suppress inflammation and the normal immune response

Well absorbed after oral administration.Absorption from local sites (intra-articular, intralesional) is slow but complete. All are metabolized mostly by the liver to inactive metabolites.

0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg.

PO, IM, IV

Daily in divided doses q 6-12 hr.IM or IV q 6 hr

Monitor serum electrolytes and glucose. CBC, serum electrolytes, and serum and urine glucose evaluated.

Cerebral edema Diagnostic agent in adrenal disorders.Management of croup Treatment of airway edema prior to extubation.

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Drug Action Kinetics Dose Route Time Lab Common diseases treated by meds.

Ferrous sulfate An essential mineral found in hemoglobin, myoglobin, and many enzymes

5-10% of dietary iron is absorbed (up to 30% in deficiency states). Therapeutically administered PO iron may be 60% absorbed via an active and passive transport process. Well absorbed following IM administration. Remains in the body for many months.

120--240 mg in 2-3 divided doses

PO Daily Monitor hemoglobin, hematocrit, and reticulocyte values prior to and every 3 wk during the first 2 mo of therapy and periodically thereafter. Serum ferritin and iron levels may also be monitored to assess effectiveness of therapy.

Iron-deficiency anemia.

Folic acid Required for protein synthesis and red blood cell function. Stimulates the production of red blood cells,

Well absorbed from the GI tract and IM and subcut sites. Distribution: Half of all stores are in the liver.Metabolism and

Tablets: 0.4 mg, 0.8 mg, 1 mgInjection: 5 mg/ml

PO, IM, SubQ, IV

Daily Monitor plasma folic acid levels, hemoglobin, hematocrit, and reticulocyte count before and periodically during therapy. .

Megaloblastic and macrocytic anemias.

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white blood cells, and platelets

Excretion: Converted by the liver to its active metabolite, dihydrofolate reductase. Excess amounts are excreted unchanged by the kidneys.

Furosemide Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium

60-67% absorbed after oral administration (↓ in acute CHF and in renal failure); also absorbed from IM sites

20 mg, 40 mg, 80 mg

PO, IM, IV

Daily Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy

HTN

Lenalidomide myelodysplastic syndrome

Morphine Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing

Absorption: Variably absorbed (about 30%) following oral administration. Following epidural administration,

PO, Rect (Adults ≥50 kg): Usual starting dose for moderate to severe pain in opioid-

PO, IM, SubQ, IV, Epidural, IT

May ↑ plasma amylase and lipase levels.

Severe pain. Pulmonary

edema. Pain

associated with MI.

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generalized CNS depression. Therapeutic Effects: Decrease in severity of pain.

systemic absorption and absorption into the intrathecal space via the meninges occurs. Distribution: Widely distributed. Crosses the placenta; enters breast milk in small amounts. Protein Binding: Premature infants: <20%; Adults: 35%.

Metabolism and Excretion: Mostly metabolized by the liver. Active metabolites excreted renally.

naive patients--30 mg q 3-4 hr initially or once 24-hr. Use preservative-free formulation. Intrathecal (Adults): 0.2-1 mg. Use preservative-free formulation.

Morphine sulfate controlled-releaseMultivitamin supplemental Replaces vitamins Once Daily PO Dependent on drug

interactionsVitamine Supplement

Ocuvite supplemental Replaces vitamins Once Daily PO Dependent on drug interactions

Phenytoin/ Dilantin

Limits seizure propagation by altering ion transport, Antiarrhythmic properties as a result of shortening the action potential

Absorbed slowly from the GI tract, Distributes into CSF and other body tissues and fluids, Mostly metabolized by the liver; minimal amounts excreted in the urine.

PO (Adults): Loading dose of 15-20 mg/kg as extended capsules in 3 divided doses given every 2-4 hr;

PO, IV, no IM

Monitor CBC, serum calcium, albumin, and hepatic function tests prior to and monthly for the first several months, then periodically throughout therapy.

Seizures

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and decreasing automaticity

maintenance dose 5-6 mg/kg/day given in 1-3 divided doses; usual dosing range = 200-1200 mg/day.

Potassium chloride

Maintain acid-base balance, isotonicity, and electrophysiologic balance of the cell.

Activator in many enzymatic reactions; essential to transmission of nerve impulses; contraction of cardiac, skeletal, and smooth musc≤ gastric secretion; renal function; tissue synthesis; and carbohydrate metabolism.

Absorption: Well absorbed following oral administration. Distribution: Enters extracellular fluid; then actively transported into cells. Metabolism and Excretion: Excreted by the kidneys.

13.4 mEqPO IV (Adults): 40-80 mEq/day. PO (Adults): 20-40 mEq/day in 1-2 divided doses; single dose should not exceed 20 mEq. PO (Adults): 40-100 mEq/day in divided doses.

PO, IV Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Determine serum magnesium level Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride.

Electrolytes imbalnace

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Sertraline/ Zoloft Inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin. Has little effect on norepinephrine or dopamine. Decreased social anxiety. Decrease in premenstrual dysphoria.

Absorption: Appears to be well absorbed after oral administration. Distribution: Extensively distributed throughout body tissues. Metabolism and Excretion: Extensively metabolized by the liver; one metabolite has some antidepressant activity; 14% excreted unchanged in feces.

PO (Adults): 50 mg/day as a single dose in the morning or evening initially; PTSDPO (Adults): 25 mg once daily for 7 days, then increase to 50 mg once daily; Social Anxiety DisorderPO (Adults): 25 mg once daily initially, then 50 mg once daily; Premenstrual Dysphoric DisorderPO (Adults): 50 mg/day initially either daily or daily during luteal phase of cycle.

PO Same time every day

Dependent on drug interaction

Major Depressive Disorder. Panic disorder. Obsessive-compulsive disorder (OCD). Post-traumatic stress disorder (PTSD). Socal anxiety disorder (social phobia). Premenstrual dysphoric disorder (PMDD). dysphoria.

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Simvastatin/Zocor Inhibit an enzyme, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which is responsible for catalyzing an early step in the synthesis of cholesterol. Therapeutic Effects: Lowers total and LDL cholesterol and triglycerides. Slightly increase HDL. Slows of the progression of coronary atherosclerosis with resultant decrease in CHD-related events (all agents except rosuvastatin have indication for ↓ events).

Absorption: Atorvastatin--rapidly absorbed but undergoes extensive GI and hepatic metabolism, resulting in 14% bioavailability; fluvastatin--98% absorbed after oral administration, but undergoes extensive first-pass metabolism resulting in 24% bioavailability; lovastatin, pravastatin--poorly and variably absorbed after oral administration; rosuvastatin--20% absorbed following oral administration; simvastatin--85% absorbed but rapidly metabolized.

SimvastatinPO (Adults): 5-80 mg once daily in the evening. Concurrent cyclosporine or danazol therapy--Initiate at 5 mg once daily; dose should not exceed 10 mg/day. Concurrent fibrate or niacin therapy-Dose should not exceed 10 mg/day. Concurrent amiodarone or verapamil therapy-Dose should not exceed 20 mg/day.

PO Evaluate serum cholesterol and triglyceride levels before initiating, after 4-6 wk of therapy, and periodically thereafter.

Monitor liver function tests, including AST, before, at 12 wk after initiation of therapy or after dose elevation, and then q 6 mo. If AST levels ↑ to 3 times normal, HMG-CoA reductase inhibitor therapy should be reduced or discontinued. May also cause ↑ alkaline phosphatase and bilirubin levels.

If patient develops muscle tenderness during therapy, monitor CK levels. If CK levels are >10 times the upper limit of normal or myopathy occurs, therapy should be discontinued. .

Warfarin Interferes with hepatic synthesis of vitamin K-

Absorption: Well absorbed from the GI tract after oral

PO IV (Adults): 2.5-10 mg/day for

PO, IV PT, INR and other clotting factors should be monitored

Prophylaxis and treatment of:

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dependent clotting factors (II, VII, IX, and X).

administration. Distribution: Crosses the placenta but does not enter breast milk. Metabolism and Excretion: Metabolized by the liver. Half-life: 42 hrs.

2-4 days; then adjust daily dose by results of prothrombin time or international normalized ratio (INR). Initiate therapy with lower doses in geriatric or debilitated patients.

frequently during therapy. Therapeutic PT ranges from 1.3-1.5 times greater than control; however, the INR, a standardized system that provides a common basis for communicating and interpreting PT results, is usually referenced. Normal INR (not on anticoagulants)is 0.8 to 1.2. An INR of 2.5 to 3.5 is recommended for patients at very high risk of embolization (for example, patients with mitral valve replacement and ventricular hypertrophy). Lower levels are acceptable when risk is lower.

Hepatic function and CBC should be monitored before and periodically throughout therapy.

Stool and urine should be monitored for occult blood before and periodically throughout therapy.

Venous thrombosis, Pulmonary embolism, Atrial fibrillation with embolization.

Management of myocardial infarction: Decreases risk of death, Decreases risk of subsequent MI, Decreases risk of future thromboembolic events.

Prevention of thrombus formation and embolization after prosthetic valve placement.

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Allergies:

Meperidine (Demerol)

What are signs and symptoms of adverse reaction?

CNS: SEIZURES, confusion, sedation, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams, EENT: blurred vision, diplopia, miosis, Resp: respiratory depression, CV: hypotension, bradycardia, GI: constipation, nausea, vomiting, GU: urinary retention. Derm: flushing, sweating, Misc: physical dependence, psychological dependence, tolerance. ;

What is the metabolite of meperidine that would cause seizures? normeperidine

Penicillin

What are signs and symptoms of adverse reaction?

CNS: SEIZURES, GI: diarrhea, epigastric distress, nausea, vomiting, pseudomembranous colitis, GU: interstitial nephritis, Derm: rashes, urticaria, Hemat: eosinophilia, hemolytic anemia, leukopenia. Local: pain at IM site , phlebitis at IV site . Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS AND SERUM SICKNESS, superinfection.

Colchicine

What are signs and symptoms of adverse reaction? GI: diarrhea, nausea, vomiting, abdominal pain. GU: anuria, hematuria, renal damage. Derm: alopecia. Hemat: AGRANULOCYTOSIS, APLASTIC ANEMIA, leukopenia, thrombocytopenia. Local: phlebitis at IV site. Neuro: peripheral neuritis.

What is the dug classification? antigout agents

Why might colchicine have been ordered? To treat gout

Body System: Place each medication under the body system that it commonly affects.

Neurological: phenytoin, morphine, morphine sulfate XR

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Pain/comfort: phenytoin, sertraline, morphine sulfate XR

Cardiovascular: phenytoin

Hematological: allopurinol, warfarin, dexamethasone, folic acid, ferrous sulfate, multivitamin, clopidogrel, furosemide, lenalidomide, potassium chloride

Pulmonary: None

Nutrition: allopurinol, folic acid, ferrous sulfate, ocuvite, multivitamin, simvastatin

Gastrointestinal: None

Genitourinary/renal: allopurinol, potassium chloride, furosemide

Musculoskeletal: dexamethasone, folic acid, ferrous sulfate, multivitamin, lenalidomide

Integumentary: None

Endocrine/Immune: dexamethasone, lenalidomide

Nursing ProcessWhat nursing assessment, planning, implementation and evaluation needs to be performed for each medication?

1. AllopurinolMonitor intake and output ratios. Decreased kidney function can cause drug accumulation and toxic effects. Ensure that

patient maintains adequate fluid intake (minimum 2500-3000 ml/day) to minimize risk of kidney stone formation. Assess patient for rash or more severe hypersensitivity reactions. Discontinue allopurinol immediately if rash occurs. Therapy

should be discontinued permanently if reaction is severe. Therapy may be reinstated after a mild reaction has subsided, at a lower dose (50 mg/day with very gradual titration). If skin rash recurs, discontinue permanently. .

Gout: Monitor for joint pain and swelling. Addition of colchicine or NSAIDs may be necessary for acute attacks. Prophylactic doses of colchicine or an NSAID should be administered concurrently during the first 3-6 mo of therapy because of an increased frequency of acute attacks of gouty arthritis during early therapy.

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2. ClopidogrelAssess patient for symptoms of stroke, peripheral vascular disease, or MI periodically during therapy. Monitor patient for signs of thrombotic thrombocytic purpura (thrombocytopenia, microangiopathic hemolytic anemia,

neurologic findings, renal dysfunction, fever). May rarely occur, even after short exposure (<2 wk). Requires prompt treatment.

3. DexamethasoneThese drugs are indicated for many conditions. Assess involved systems before and periodically during therapy. Assess patient for signs of adrenal insufficiency (hypotension, weight loss, weakness, nausea, vomiting, anorexia, lethargy,

confusion, restlessness) before and periodically during therapy. Monitor intake and output ratios and daily weights. Observe patient for peripheral edema, steady weight gain, rales/crackles,

or dyspnea. Notify health care professional if these occur. Children should have periodic evaluations of growth. Cerebral Edema: Assess patient for changes in level of consciousness and headache during therapy.

4. Ferrous sulfateAssess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. Assess bowel function for constipation or diarrhea. Notify health care professional and use appropriate nursing measures

should these occur. Iron Dextran, Iron Sucrose, and Sodium Ferric Gluconate Complex: Monitor blood pressure and heart rate frequently

following IV administration until stable. Rapid infusion rate may cause hypotension and flushing. Assess patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify physician

immediately if these occur. Keep epinephrine and resuscitation equipment close by in the event of an anaphylactic reaction.

5. Folic acidAssess patient for signs of megaloblastic anemia (fatigue, weakness, dyspnea) before and periodically throughout therapy.

6. Furosemide

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Assess fluid status. Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes. Notify physician or other health care professional if thirst, dry mouth, lethargy, weakness, hypotension, or oliguria occurs.

Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension.

Geri: Diuretic use is associated with increased risk for falls in older adults. Assess falls risk and implement fall prevention strategies.

Assess patients receiving digoxin for anorexia, nausea, vomiting, muscle cramps, paresthesia, and confusion. Patients taking digoxin are at increased risk of digoxin toxicity because of the potassium-depleting effect of the diuretic. Potassium supplements or potassium-sparing diuretics may be used concurrently to prevent hypokalemia.

Assess patient for tinnitus and hearing loss. Audiometry is recommended for patients receiving prolonged high-dose IV therapy. Hearing loss is most common after rapid or high-dose IV administration in patients with decreased renal function or those taking other ototoxic drugs.

Assess for allergy to sulfonamides. Lenalidomide

7. MorphineAssess type, location, and intensity of pain prior to and 1 hr following PO, subcut, IM, and 20 min (peak) following IV

administration. When titrating opioid doses, increases of 25-50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting morphine a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

Patients on a continuous infusion should have additional bolus doses provided every 15-30 min, as needed, for breakthrough pain. The bolus dose is usually set to the amount of drug infused each hour by continuous infusion.

High Alert: Assess level of consciousness, blood pressure, pulse, and respirations before and periodically during administration. If respiratory rate is <10/min, assess level of sedation. Physical stimulation may be sufficient to prevent significant hypoventilation. Subsequent doses may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use.Geri: Assess geriatric patients frequently; older adults are more sensitive to the effects of opioid analgesics and

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may experience side effects and respiratory complications more frequently.Pedi: Assess pediatric patient frequently; children are more sensitive to the effects of opioid analgesics and may experience respiratory complications, excitability and restlessness more frequently.

Prolonged use may lead to physical and psychological dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive morphine for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2-3 days, unless contraindicated.

8. Morphine sulfate controlled-releasePatients taking sustained-release morphine may require additional short-acting opioid doses for breakthrough pain. Doses should be equivalent to 10-20% of 24 hr total and given every 2 hr as needed.

9. PhenytoinAssess oral hygiene. Vigorous cleaning beginning within 10 days of initiation of phenytoin therapy may help control gingival

hyperplasia. Assess patient for phenytoin hypersensitivity syndrome (fever, skin rash, lymphadenopathy). Rash usually occurs within the

first 2 wk of therapy. Hypersensitivity syndrome usually occurs at 3-8 wk but may occur up to 12 wk after initiation of therapy. May lead to renal failure, rhabdomyolysis, or hepatic necrosis; may be fatal. .

Seizures: Assess location, duration, frequency, and characteristics of seizure activity. EEG may be monitored periodically throughout therapy.

Monitor blood pressure, ECG, and respiratory function continuously during administration of IV phenytoin and throughout period when peak serum phenytoin levels occur (15-30 min after administration). .

Arrhythmias: Monitor ECG continuously during treatment of arrhythmias.

10. Potassium chlorideAssessment

Assess for signs and symptoms of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and

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hyperkalemia (see Toxicity and Overdose). Monitor pulse, blood pressure, and ECG periodically during IV therapy.

ImplementationHigh Alert: Medication errors involving too rapid infusion or bolus IV administration of potassium chloride have resulted in

fatalities. See IV administration guidelines below. Do not confuse K-Dur with Imdur (isosorbide mononitrate). Do not confuse Micro-K with micronase (glyburide). For most purposes, potassium chloride should be used, except for renal tubular acidoses (hyperchloremic acidosis), in which

other salts are more appropriate (potassium bicarbonate, potassium citrate, or potassium gluconate). If hypokalemia is secondary to diuretic therapy, consideration should be given to decreasing the dose of diuretic, unless there

is a history of significant arrhythmias or concurrent digitalis glycoside therapy. . PO: Administer with or after meals to decrease GI irritation.

Evaluation/Desired OutcomesPrevention and correction of serum potassium depletion. Cessation of arrhythmias caused by digoxin toxicity.

11. SertralineAssessment

Monitor appetite and nutritional intake. Weigh weekly. Notify health care professional of continued weight loss. Adjust diet as tolerated to support nutritional status.

Depression: Monitor mood changes. Inform physician or other health care professional if patient demonstrates significant increase in anxiety, nervousness, or insomnia.

Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. OCD: Assess patient for frequency of obsessive-compulsive behaviors. Note degree to which these thoughts and behaviors

interfere with daily functioning. Panic Attacks: Assess frequency and severity of panic attacks. PTSD: Assess patient for feelings of fear, helplessness, and horror. Determine effect on social and occupational functioning. Social Anxiety Disorder: Assess patient for symptoms of social anxiety disorder (blushing, sweating, trembling, tachycardia

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during interactions with new people, people in authority, or groups) periodically during therapy. Premenstrual Dysphoric Disorder: Assess patient for symptoms of premenstrual dysphoric disorder (feeling angry, tense, or

tired; crying easily, feeling sad or hopeless; arguing with family or friends for no reason; difficulty sleeping or paying attention; feeling out of control or unable to cope; having cramping, bloating, food craving, or breast tenderness) periodically during therapy. Implementation

Do not confuse sertraline with selegiline. Periodically reassess dose and continued need for therapy. . PO: Administer as a single dose in the morning or evening.

Evaluation/Desired OutcomesIncreased sense of well-being. Renewed interest in surroundings. May require 1-4 wk of therapy to obtain antidepressant effects. . Decrease in obsessive-compulsive behaviors. Decrease in frequency and severity of panic attacks. Decrease in symptoms of PTSD. Decrease in social anxiety disorder. Decrease in symptoms of premenstrual Dysphoric

12. SimvastatinAssessment

Obtain a dietary history, especially with regard to fat consumption. Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels before initiating, after 4-6 wk of therapy, and

periodically thereafter. Monitor liver function tests, including AST, before, at 12 wk after initiation of therapy or after dose elevation, and then q 6 mo.

If AST levels ↑ to 3 times normal, HMG-CoA reductase inhibitor therapy should be reduced or discontinued. May also cause ↑ alkaline phosphatase and bilirubin levels.

If patient develops muscle tenderness during therapy, monitor CK levels. If CK levels are >10 times the upper limit of normal or

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myopathy occurs, therapy should be discontinued. . Implementation

Do not confuse Pravachol (pravastatin) with Prevacid (lansoprazole). PO: Administer lovastatin with food. Administration on an empty stomach decreases absorption by approximately 30%. Initial

once-daily dose is administered with the evening meal . Administer extended-release tablets at bedtime. Extended-release tablets should be swallowed whole, do not crush, break, or

chew. Administer fluvastatin, pravastatin, and simvastatin once daily in the evening. Atorvastatin and rosuvastatin can be taken any

time of day. May be administered without regard to food. Avoid large amounts of grapefruit juice during therapy; may ↑ risk of toxicity. If fluvastatin or pravastatin is administered in conjunction with bile acid sequestrants (cholestyramine, colestipol), administer

at least 4 hr after bile acid sequestrant. If rosuvastatin is administered in conjunction with magnesium or aluminum-containing antacids, administer antacid at least 2

hr after rosuvastatin. Decrease in LDL and total cholesterol levels. Increase in HDL cholesterol levels. Decrease in triglyceride levels. . Slowing of the progression of coronary artery disease.

13. WarfarinAssessment

Obtain a dietary history, especially with regard to fat consumption. Lab Test Considerations: Evaluate serum cholesterol and triglyceride levels before initiating, after 4-6 wk of therapy, and

periodically thereafter. Monitor liver function tests, including AST, before, at 12 wk after initiation of therapy or after dose elevation, and then q 6 mo.

If AST levels ↑ to 3 times normal, HMG-CoA reductase inhibitor therapy should be reduced or discontinued. May also cause ↑

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alkaline phosphatase and bilirubin levels. If patient develops muscle tenderness during therapy, monitor CK levels. If CK levels are >10 times the upper limit of normal or

myopathy occurs, therapy should be discontinued.Implementation

Do not confuse Pravachol (pravastatin) with Prevacid (lansoprazole). PO: Administer lovastatin with food. Administration on an empty stomach decreases absorption by approximately 30%. Initial

once-daily dose is administered with the evening meal . Administer extended-release tablets at bedtime. Extended-release tablets should be swallowed whole, do not crush, break, or

chew. Administer fluvastatin, pravastatin, and simvastatin once daily in the evening. Atorvastatin and rosuvastatin can be taken any

time of day. May be administered without regard to food. Avoid large amounts of grapefruit juice during therapy; may ↑ risk of toxicity. If fluvastatin or pravastatin is administered in conjunction with bile acid sequestrants (cholestyramine, colestipol), administer

at least 4 hr after bile acid sequestrant. If rosuvastatin is administered in conjunction with magnesium or aluminum-containing antacids, administer antacid at least 2

hr after rosuvastatin.Decrease in sLDL and total cholesterol levels. Increase in HDL cholesterol levels. Decrease in triglyceride levels. . Slowing of the progression of coronary artery disease.

Physical Assessment Findings

Neurological Assessment: Pleasant, alert, oriented to time and place, Pupils equal, round and reactive to light, patient wears glasses, Weakness noted in all extremities

Pain/Comfort Assessment: Burring sensation in hands and feet, Deep aching in hip area, Unable to stand without assistance or button his shirt because of pain

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Cardiovascular and hematological assessment: K3.5, S 1 S 2 monitor reveals sinus of 79, Blood pressure 100/50 no edema, extremities pale capillary refill at 3 seconds, Bruising to upper extremities and bruising noted on shins bilaterally, History of absolute neutrophil count <1000, Platelets 175,000; RBC 4.0 - Hct 29; Hgb 10; WBC 3000

Pulmonary Assessment: Clear throughout with respiratory rate of 16 per minutes, 02 at 2 L (presently wearing), ox sat at 94%

Nutrition/Gastrointestinal Assessment: Oral cavity pale, wears dentures, but state that his mouth hurts and he cannot wear them, Has lost 55 pounds in 2 weeks

Genitourinary Assessment: Denies problems

Musculoskeletal Assessment: Noted muscle weakness, unable to stand without assistance

Integumentary: Bruising noted to upper extremities, bruising noted on skins bilaterally, Notes redness and IV site on right antecubital 0.9 NS

Endocrine/ Immune assessment: History of absolute neutrophil count <1000; Platelets 175,000; RBC 4.0 Hct 29 Hgb 10; WBC 3,000; Labs within normal findings; no outward signs of problems

Physician Orders

CBCINRLeukocyte alkaline phosphate

Develop:

Two nursing diagnosis (NANDA)

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1. Risk for infection

2. Acute Pain

3 patient outcomes (NOC)

1. Patient will remain free from infection

2. Patient will report pain <3/10

3. Patient will demonstrate appropriate relaxation techniques to alleviate pain

3 patient interventions (NIC)

1. Assess pain level and administer medications as needed

2. Assess for infection and teach standard precautions

3. Teach relaxation techniques

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