The Impact of the Clients Biochemical Results - Assignment Example

1. Analyze the impact of the client’s biochemical results on their health and diagnosed disease process. The biochemistry results reveal hyponatremia, hypokalemia, and hypocholeremia. This indicates that there is an electrolyte imbalance caused by the diarrhea. There is also hypophosphatemia (probably due to poorly controlled diabetes). Since there is no bacterial or viral growth in the stool specimen, the diarrhea could be a side effect of metformin. The patient is a known diabetic on diet control and medication. The blood glucose levels were probably low initially (because he has not eaten anything since the diarrhea), and then rose to a high level, probably indicating a poor control of the diabetes. His C-reactive protein level is high. C-reactive protein is produced by the liver. The level of CRP rises when there is systemic inflammation anywhere in the body (Medline plus, n.d.) A study by Boehme, Autschbach, Raeth, 2007 showed that in patients with diabetes mellitus, there is a high prevalence of severe acute gastric inflammation or ulcer disease. Raised levels of C-reactive-protein or blood leukocyte counts in such patients indicate a diagnostic endoscopy. 2. Discuss the common drugs used for specific body systems including pharmacokinetics as applied to the client in the case study. The patient was previously on the following drugs: metformin hydrochloride 500mg before the morning and evening meal, simvastatin 10mg once daily, H.S, 100mg of aspirin daily, and atenolol 50mg. Metformin is a biguanide oral antidiabetic drug. It is completely absorbed from the gastrointestinal tract within 6 hours of ingestion (Scheen, 1996). It is rapidly distributed following absorption and does not bind to plasma proteins. There is no liver metabolism (Scheen, 1996). Metformin undergoes renal excretion and has a mean plasma elimination half-life of between 4.0 and 8.7 hours (Scheen, 1996.) Simvastatin belongs to the statin group of drugs. It is used to control hypercholesterolemia and to prevent cardiovascular disease. Following an oral dose of simvastatin, 13% is excreted in urine and 60% in feces (Laurence & Bennet, 1992.) Plasma concentrations peaks at 4 hours. Simvastatin undergoes extensive first-pass extraction in the liver, and thus there is low availability of the drug in the general circulation (Laurence & Bennet, 1992.) Aspirin is a NSAID and has analgesic and antipyretic activities. It is well absorbed from the stomach and upper intestinal tract. Hydrolysis removes the acetyl group and the resulting salicylate ion is inactivated by conjugation with glycine. At therapeutic doses, this reaction proceeds with a t1/2 of 4 hours. Steady plasma concentration can be maintained if given 6-hourly (Laurence & Bennet, 1992.) Atenolol is a beta1-selective (cardioselective) beta-adrenergic receptor blocking agent. Approximately 50% of an oral dose is absorbed from the gastrointestinal tract, the remainder being excreted unchanged in the feces (Laurence & Bennet, 1992). Peak blood levels are reached between 2-4 hours after ingestion. It undergoes little or no metabolism by the liver, and the absorbed portion is eliminated primarily by the kidneys (Laurence & Bennet, 1992.) 3. Address microbial control and the issues surrounding the collection of the MSU and stool culture and the commencement of antibiotic therapy. Microbial control is achieved with antimicrobials. Antimicrobials may be classified according to the type of organism against which they are active and includes: antibacterials, antivirals, antifungals, antiprotozoals, and antihelminthic drugs (Laurence & Bennet, 1992.) Antimicrobials may also be classified broadly into bacteriostatic-which acts by arresting bacterial growth, and bactericidals-which acts by killing bacteria (Laurence & Bennet, 1992.) The choice of antimicrobials is based on the identification of the microbe and sensitivity tests (Laurence & Bennet, 1992.) All appropriate specimens like blood, pus, urine, sputum, CSF etc are collected and examined before administering medications (Laurence & Bennet, 1992). However, in certain situations, medication may be started based on the knowledge of the most likely pathogen in a clinical situation, before culture and sensitivity tests are obtained (Laurence & Bennet, 1992.) MSU or midstream specimen of urine is indicated for continent adults and children who can empty their bladder on request, especially if a urinary tract infection (UTI) is suspected. However, despite being a common nursing activity, this procedure is often performed wrongly (Gilbert, 2006.) Taking a midstream specimen of urine involves discarding the first few milliliters of urine and the collection of the midstream specimen into a sterile container (NHS, 2008). The collected MSU must be examined immediately or refrigerated if this is not possible (Lifshitz & Kramer, 2000). If there is a delay of more than two hours between collection and examination, it can lead to unreliable results (Lifshitz & Kramer, 2000). Although in women, a prior cleansing of the external genitalia is often recommended, it has no proven benefit (Lifshitz & Kramer, 2000). Although a MSU culture growing more than 10(5) colony-forming units per milliliter (cfu/mL) has been considered diagnostic of UTI, this method has been associated with high false-positive rates, false-negative rates and a lack of precision (Werman & Brown, 1986.) A stool culture is required for the isolation and identification of enteric bacterial pathogens. However, it is not indicated if the onset of diarrhea is ≥ 4 days after hospitalization regardless of the age of the patient or their immune status, since there is a very low yield of finding enteric infections (Alberta CPG working group, 2008). It is also not indicated when an infectious etiology is not a consideration (Alberta CPG working group, 2008). Although death from diarrhea is rare, there is a greater risk in those older than 74 years and those in long-term care facilities. It has been shown that in community-acquired diarrhea, an empiric treatment with ciprofloxacin shortens the duration of diarrhea by one to two days. Antibiotic treatment, is however, best reserved for patients who do not respond to hydration and treatment with anti-diarrheals like loperamide (Sadovsky, 2000). 4. Discuss safe practice in the administration of medications and ethical, legal and professional practice issues concerned with medication administration. The single most common type of medical error in hospitals is medication errors, and they are the major cause of iatrogenic illness, prolonged hospitalizations and injury to patients in hospitals (Fiesta, 1998; Kaushal et. al., 2001; Lesar, Lomaestro, & Pohl, 1997). Medication errors are mostly due to documentation issues like: illegible handwriting, misunderstanding abbreviations, misplaced decimal point, and misreading and misinterpreting written orders (Deans, 2005). Potential causes of medication errors include human factors like: stress, fatigue, inadequate knowledge and skill, and environmental factors like interruptions and distractions during the administration of medications (Deans, 2005.) Medication errors could be reduced by systematically identifying, eliminating, or minimizing human and system risks (Bates, 2007). Technologies like computerized order entry, bar-coding and smart pumps and computerized ADE monitoring, will prevent medication errors (Bates, 2007). Nurses need to be trained further in administering medication and spend more time with patients when administering medications (Deans, 2005.) A model for safe medication practices (modified from Florida Society of Health System) is given below: a. Make available essential patient information, including allergies, age, weight, current diagnoses, relevant laboratory values, and current medication regimen. b. Those who administer medication should have immediate access to appropriate and current drug reference texts and/or online resources. c. Those who administer medication should know about the drug’s uses, precautions, contraindications, potential adverse reactions, interactions, and method of administration. d. Those who administer medication should clarify any order that is incomplete, illegible, or otherwise questionable. e. Verify the dispensed medication with the original order and Medication Administration Record (MAR). f. Note both the brand and generic drug name on the Medication Administration Record (MAR). g. Administer only medication that have been fully labeled with medication name, dose, dosage form, route, special storage requirements, expiry date, and all other applicable warnings. h. Create an environment for administration that minimizes distractions and interruptions, provides appropriate lighting, safe noise levels, and includes ergonomic consideration of equipment, fixtures, and technology. i. Utilize a standard medication administration time schedule. 5. Describe safe practice in the administration of the blood transfusion including accuracy in IV fluid calculation techniques. The safe practice in blood transfusion includes policies on patient identification, proper implementation, and monitoring throughout the blood transfusion process, starting from the prescription, sampling, laboratory testing and issue of blood, to the final collection and administration of the blood (Hill, 2007.) Proper patient identification includes handwritten or printed wristbands, bar-coded wristbands and the use of photographic evidence (for those whose clinical conditions prevent the wearing of wristbands). In addition, policies covering phlebotomy, minimum labeling requirements and issue, blood collection and bedside checking and administration, should be in place (Hill, 2007). There should be proper preoperative planning (like treating anemia), the use or cessation of pharmacological agents (e.g. antiplatelet drugs to prevent bleeding during surgery), surgical techniques, and the adoption of transfusion triggers. Consideration should also be given to the use of alternatives to donated blood transfusion like cell salvage, autologous transfusions, and the use of blood substitutes (Hill, 2007.) Following is the checklist for prescribing blood in non-urgent situations (modified from Australian red cross, 2006): a. Decide and discuss with patient / relatives. b. Check for any special requirements. c. Document in case notes and write the prescription. d. Complete the request form and ensure that a current specimen is available. e. Communicate with the nursing and transfusion service staff. f. Immediately recognize, respond, and report any adverse effect to the transfusion service. By adjusting the roller, the nurse can set the IV rate to the correct amount of drops per minute, and thus ensure accuracy (Martelli, n.d). When on a pump, the IVs must be checked hourly. If the fluid is ordered for every eight hours or for a 24-hour period, the first calculation is to determine how much fluid is ordered per hour (Martelli, n.d). This is determined by dividing the total amount of fluid by the total time ordered for delivery. In case an IV pump is used, only the rate per hour needs to be calculated, since IV pumps automatically deliver an hourly rate of IV fluid (Martelli, n.d) The next step is to convert the drops per hour into drops per minute. For this calculation, divide the number of ccs to be delivered per hour by 60 and multiply by the drip factor of the IV administration set. Once the drip rate per minute is thus determined, the flow of the IV can be regulated according to the order (Martelli, n.d) 6. Develop a health-teaching plan for the client that presents information on his discharge medications, including correct time to take the medication and pharmacodynamics. The teaching plan may be presented in table format. Drug Time Pharmacodynamics Metformin 10mg Morning and night Might potentiate the effect of insulin or enhance the effect of insulin on the peripheral receptor site. Increases glucose uptake in peripheral tissues (Laurence & Bennet, 1992.) Atenolol 50mg Once daily β1-selective (cardioselective) drug, which slows heart rate and reduces its workload (Laurence & Bennet, 1992.) Nexium Hp7 1 E (morning & night) 2 A (morning & night) 1 C (morning & night) Comprises esomeprazole (E), amoxycillin (A) and (clarithromycin (C). Esomeprazole is a proton-pump inhibitor, and it decreases the amount of acid produced by the stomach. Amoxycillin and clarithromycin are both antibiotics, which kill Helicobacter pylori (Laurence & Bennet, 1992.) Paracetamol S.O.S Analgesic and antipyretic (Laurence & Bennet, 1992.) ************************************************************************ References Alberta CPG working group (2008). Laboratory guideline for ordering stool test for investigation of suspected infectious diarrhea. Retrieved April 11, 2008, from http://www.topalbertadoctors.org/NR/rdonlyres/288F1723-930B-43A2-9043-0D3EB34F2F70/0/diarrhea_guideline.pdf. Australian red cross (2006). Transfusion basics. Retrieved April 11 from, www.transfuse.com.au Bates, DW (2007). Preventing medication errors: a summary. Am J Health Syst Pharm. 64(14). Boehme, MW, Autschbach, F, Ell, C, Raeth, U (2007). Prevalence of silent gastric ulcer, erosions or severe acute gastritis in patients with type 2 diabetes mellitus-a cross-sectional study. Hepatogastroenterology. 54(74):643-8. Deans, C (2005). Collegian. 12(1):29-33. Fiesta, J. (1998). Legal aspects of medication administration. Nursing Management. 29:22-23. Florida Society of Health System (n.d). Model for safe medication practices for hospitals. Retrieved April 11 from, http://www.fha.org/acrobat/administrationrevised2901.pdf. Gilbert, R (2006). Taking a midstream specimen of urine. Nurs Times. 102(18):22-3. Hill, B (2007). A toolkit for better blood transfusion. The Biomedical scientist. Kaushal, R, Bates, D.W, Landrigan, C, McKenna, K.J, Clapp, M.D, Federico, F, and Goldman, D (2001). Medication errors and adverse drug events in pediatric inpatients. JAMA. 285: 2114-2120. Kohn, L.T, Corrigan, J.M, and Donaldson, M.S, (2000). (Editors). 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American Family Physician. 62(11). Scheen, AJ (1996). Clinical pharmacokinetics of metformin. Clin Pharmacokinet. 30(5):359-71. Werman, HA, Brown, CG (1986). Utility of urine cultures in the emergency department. Ann Emerg Med. 15(3):302-7. Read More