D6R

D6R

• You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts.
• All replies must be constructive and use literature where possible cited in current APA style with support from at least 1 academic sources for each response.

 

Mrs. P. is an 80-year-old woman recently discharged from a 24-hour observation stay at the hospital after being diagnosed with acute bronchitis. She has a history of heart failure, hypertension, osteoarthritis, GERD, and hyperlipidemia. She has no history of smoking. While in the hospital she was prescribed doxycycline, prednisone 15 mg to taper, and a tiotropium inhaler. Her current list of daily medications prior to hospitalization includes metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 meq bid, acetaminophen 650 mg bid for pain and tramadol 25 mg as needed. She lives alone but will reside temporarily with her daughter while she recovers. Her discharge report indicated resolving bronchitis, no exacerbation of heart failure, and stable arthritic pain. Today she reports 1 week after discharge with her daughter for a primary care appointment, and they both were concerned about the number of medications she was prescribed and wanted her medications reviewed. In further review, she was found to have lost weight over the past 6 months of 5 lbs and her current BMI is 25. She states that the weight loss may be due to a change to a healthier diet and reducing sodium as instructed. She also reports no symptoms of GERD for the past 6 months and minimal arthritic pain because of regular use of acetaminophen and daily walking in the halls of her independent living facility. Upon examination her lungs are clear to auscultation and no evidence of lower extremity edema.

• Discuss the following:
• 1) In reviewing her medication list and current symptoms and clinical signs, which
  medication could the nurse practitioner consider de-prescribing.
• 2) Once the patient has completed the prednisone taper, which medication could the nurse
  practitioner begin to reduce given the patient’s reported symptoms.
• 3) Given the absence of an exacerbation of heart failure and compliance with a reduced
  sodium diet, what other medication(s) adjustments could the nurse practitioner consider at
  this time.

 

 

RESPONSE 1

The nurse practitioner should consider de-prescribing which consist in re-evaluation of the efficacy and necessity of a drug for a specific patient done in conjunction with patient and family, in this case discontinue or reduce medications in a safe manner (Kennedy-Malone., Martin-Plank., & Duffy, 2019). According to Beers Criteria which establish a list of PIMs (potential inappropriate medications) to be avoid in older adults’ patients related to their list of drug and diagnoses. The nurse practitioner should prioritize de-prescribing in terms of drug with least benefit/ or ratio and least chance of problem from withdrawal or chance disease exacerbation when withdrawn. For example, acetaminophen 650 mg bid indicate for OA (osteoarthritis) should be reduce to 1 tablet daily as needed for pain. Acetaminophen 650 mg is the first line of treatment for OA, this patient with mild symptoms of arthritic pain should be considered lower dosage due liver toxicity. Tramadol 25 mg as needed for pain should be discontinued due to patient reports symptoms of minimal pain. This medication is indicated only for pain moderate to severe. Tramadol is considered an opioids medication that should be used with caution among elderly patient; the most common side effects are hyponatremia, constipation, dizziness, nausea, somnolence, and dependence to medications.

Pantoprazole 40 mg indicated for GERD and other gastrointestinal discomfort related to medications such as prednisone15 mg. It should be lowered to pantoprazole 20mg (low dose) once daily due to patient reports no symptoms of esophageal reflux, and stopped taking prednisone 15mg. Pantoprazole produce a risk of osteoporosis, bone and hip fracture in older adults, hypomagnesemia, C. Difficile infection, vitamin B12 deficit, and community acquired pneumonia (Codina, 2021).

Loop diuretics such as Lasix (furosemide) is a diuretic medication preferred used in patient with congestive heart failure, in this case the furosemide 40mg should be lowered to 20mg daily due to absence of symptoms of pulmonary edema, and no peripheral edema. KCL 20MEq should be discontinue it based on the current symptoms of no exacerbation of heart failure, hypertension controlled, no lower extremities edema, no pulmonary edema. In addition, potassium chloride interferes with patient’ current medications such as lisinopril 10mg and metoprolol succinate 12.5mg. According to (Codina, 2021) is important use with caution potassium chloride supplements together with ACEs inhibitors (lisinopril) due to increase the risk of hyperkalemia.

Lastly, beta-adrenergic blockers (metoprolol 12.5 mg, minimal dose) are indicated in patients with congestive heart failure (CHF) together with ACEs inhibitors (lisinopril 10mg, minimum dose). Statin drug class (atorvastatin 10mg), the use of a minimum dose is considered safe in older patient with comorbities for example heart disease, hypertension, hyperlipidemia. Always should be monitored the side effects of statins such as hepatic injury, myopathy, cognitive dysfunction and use the lower dose in elderly patients.

In any clinical decision during patient’s care, the medication benefit most outweigh the associate risk. Due to chronic conditions of congestive heart failure, hypertension and hyperlipidemia in this case, the medications metoprolol succinate 12.5mg, lisinopril 10mg, and atorvastatin 10mg should be keep it.

 

RESPOSE 2

Case 5 study present Mrs. P., an 80-year-old woman, who was recently discharged from the hospital with the diagnosis of acute bronchitis. Looking at Mrs. P’s prescription list, it appears that she is taking several prescription medications that she no longer requires. This discussion will evaluate and update her current list of medications, supporting with her current symptoms and health status.

In reviewing her medication list and current symptoms and clinical signs, which
medication could the nurse practitioner consider de-prescribing.

Elderly adults have several physiological changes that may have an impact on the various medications they are taking. Every time a patient’s condition changes, the nurse practitioner should review the patient’s drug list. In accordance with Mrs. P’s current symptoms and clinical signs, the nurse practitioner should stop Mrs. P’s 40 mg pantoprazole dose as the patient has not reported any GERD symptoms for the last six months. Tramadol 25 mg as needed. The nurse practitioner might think about reducing the frequency or amount of Tramadol because Mrs. P. experiences no arthritis discomfort because of her regular acetaminophen use and daily walking. But it is crucial to regularly monitor her pain levels and make sure she is comfortable without sacrificing her mobility or quality of life. Tramadol should be de-prescribed. Mrs. P.’s compliance with a low-sodium diet and the lack of a worsening of Mrs. P’s heart failure allow the nurse practitioner to think about lowering the furosemide, a diuretic frequently used to control fluid retention in heart failure. Since her heart failure has not gotten worse and there is no sign of lower extremities edema, the nurse practitioner could consider reducing the dose of furosemide. This can be done gradually under medical supervision to ensure that her fluid balance remains stable. Close monitoring of her weight, blood pressure, and symptoms of fluid overload would be necessary during the dose reduction. Furosemide can cause potassium loss because it is a diuretic. The nurse practitioner may also decide to change the potassium chloride supplement because the amount of furosemide may be decreased. If Mrs. P.’s potassium levels are within the normal range, it might be suitable to reduce the potassium chloride dose or frequency. It would be crucial to regularly check her electrolyte levels while making any changes to the potassium chloride supplement. After reviewing her medications, Mrs. P’s  should continue taking doxycycline, prednisone 15mg to taper, and tiotropium inhaler for acute bronchitis. Metoprolol succinate 12.5 mg for maintenance pf heart failure, lisinopril 10 mg for hypertension, atorvastatin 10 mg for hyperlipidemia, and acetaminophen 650 mg as need it for pain.

Once the patient has completed the prednisone taper, which medication could the nurse practitioner begin to reduce given the patient’s reported symptoms.

            Prednisone and other steroids must be tapered gradually until the entire dose has been taken. The process of tapering aids in avoiding withdrawal, as well as other negative effects such as headaches, fever, joint pain, and adrenal crisis (Arcanglo et al., 2017). As the patient has improving symptoms such as no edema in lower extremities, her medication such as metoprolol can be decreased. Acetaminophen can also be eliminated, and patient should continue with her daily walking, swimming, dancing. However, this decision should be made based on patient’s assessment of pain level.

Given the absence of an exacerbation of heart failure and compliance with a reduced sodium diet, what other medication(s) adjustments could the nurse practitioner consider at this time.

            A common diuretic for treating fluid retention in heart failure is furosemide. The dose of furosemide could be decreased if Mrs. P. is not exhibiting any indications or symptoms of fluid excess, such as lower extremity edema, and her heart failure is still stable. Together with a cardiologist or primary care physician, this choice should be made while considering the patient’s general clinical health and fluid status (Huang at al., 2022). The requirement for potassium supplementation with potassium chloride may also be reevaluated once the dose of furosemide is lowered. The potassium chloride supplements may no longer be required if Mrs. P.’s potassium levels are within the normal range, and she is eating a healthy diet.