Chamberlain College of Nursing

NR292 Pharmacology II

CASE STUDY #1

Mrs. Chang is an 80-year-old Asian female with terminal small-cell carcinoma of the right lung with brain metastases. The patient is on your palliative care unit and frequently reports intense breakthrough pain. Data Obtained From Nursing Assessment Vital signs: afebrile; pulse, 92; blood pressure, 112/86; respiration, 28 Dyspneic Weight: 96 pounds Height: 5 feet, 2 inches Lung sounds: bilateral rales and gurgling; improved after nebulization therapy Confused, restless, and agitated Bowel sounds diminished in all four quadrants Last bowel movement 2 days ago Speaks few words in English; family members at the bedside can translate Points to 4 pain rating on FACES pain scale Has used 6 rescue doses for pain in last 24 hours

Lab Data CBC shows anemia: Hb 9 Pulse oximetry: 92% on 02 2L/NC

Current Drug Therapy Fentanyl 75 transdermal patch, change q72h Morphine, 13 mg IM qh prn for breakthrough pain Amitriptyline, 150 mg PO bid Albuterol solution for inhalation, 2.5 mg, diluted to 3 mL with normal saline via nebulizer, three to four times daily

Case Study Questions: 1. How do these drugs work together to address Mrs. Changs underlying pathologic conditions? (15 pts) Fentanyl helps to control the patients severe chronic pain. It provides a continuous opioid analgesic to the patient that alters the patients perception of pain. Morphine also helps to control the patients pain by altering that patients perception of pain by binding to the opiate receptors. Amitriptyline is an antidepressant. This medication can help with chronic pain as well anxiety that the patient can be having from the state of her current condition. Albuterol is a bronchodilator used as a quick-relief agent. This medication can help with the patients dyspnea. 2. Are there any contraindications or precautions that would eliminate the use of these drugs for Mrs. Chang? (10 pts) NR292 Case Study 1 campus.docx New 8/9/2011 rc 1

Chamberlain College of Nursing

NR292 Pharmacology II
While the patient is on morphine you need to watch for interactions with tricyclic antidepressants like the amitriptyline because it can increase the CNS depression in the patient. When fentanyl is used with other opioids like morphine it increases the patients risk of CNS depression, hypoventilation, and hypotention. 3. What patient variables are most important to consider for Mrs. Chang when assessing her drug therapy? (10 pts) Mrs. Chang is 80 years old which puts her in the geriatric population. That means that the drugs the patient is receiving are going to metabolize slower and be excreted out of the patients system at a slower rate. Also the dose of the medication may need to be decreased in order to decrease the patients confusion. Confusion in any patient can lead to falls and many other adverse events. Also since the patient is in the geriatric population their bowels tend to move slower as well so they will require more help with a bowel regimen. Which could include the use of laxatives or more bulk in the patients diet. 4. Which of the findings from the nursing assessment demonstrate effectiveness of drug therapy? (10 pts) There are no significant findings in the assessment that show great effectiveness of the drug therapy the patient is currently receiving. The only finding is that the patients rales and gurgling in the lungs improve after the nebulization therapy of albuterol. 5. Which of the findings from the nursing assessment demonstrate possible adverse effects from drug therapy? (10 pts) The patient has not had a bowel movement for the past 2 days which are common adverse effects of fentanyl, morphine, and amitriptyline. The patient also has diminished bowel sounds in all four quadrants which could also be a complication of fentanyl, morphine, and amitriptyline. The patients restlessness can be a side effect of fentanyl and albuterol. The patients confusion can be a side effect of morphine and fentanyl. 6. What nursing actions can be done to maximize therapeutic effects? (10 pts) You can maximize the therapeutic doses of the medication by scheduling around the clock dosing of the pain medication in order to try and relieve the breakthrough pain. Also you can teach the patient relaxation techniques in order to relieve the patients pain in other ways besides with medication. 7. What nursing actions can be done to minimize adverse effects? (10 pts) To minimize the adverse effects of some of the medication you can give a laxative like senna in order to keep the bowels moving in the patient while she is still receiving multiple pain medications. Also maybe the patient can be taken on short walks around the nurses station in order to get the patients bowels moving. Also, you can increase the bulk in that patients diet in order to decrease the constipation the patient is currently presenting with. 8. What teaching is required for Mrs. Chang and her family regarding the drug therapy? Include list of any additional data needed to determine appropriate teaching. (25 points) NR292 Case Study 1 campus.docx New 8/9/2011 rc 2

Chamberlain College of Nursing

NR292 Pharmacology II
Fentanyl: Apply the patch to a flat, nonirritated, and nonirradiated site such as the chest, back, flank, or upper arm. The patch may be worn while showering, bathing, and swimming. May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities requiring alertness until response to the medication is known. Advise the patients that fever, electric blankets, heating pads, saunas, hot tubs, and heated water beds increase the release of fentanyl from the patch. Morphine: May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities requiring alertness until response to medication is known. Advise patient to change positions slowly to minimize orthostatic hypotension. Caution patient to avoid concurrent use of alcohol or other CNS depressants with this medication. Encourage patients who are immobilized or on prolonged bed rest to turn, cough, and breathe deeply every 2 hr to prevent atelectasis. Emphasize the importance of aggressive prevention of constipation with the use of morphine. Amytriptyline: Administer medication with or immediately after a meal to minimize gastric upset. Tablet may be crushed and given with food or fluids. May cause drowsiness and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to drug is known.Orthostatic hypotension, sedation, and confusion are common during early therapy, especially in geriatric patients. Protect patient from falls and advise patient to make position changes slowly. Institute fall precautions. Advise patient to make position changes slowly. Refer as appropriate for nutrition/weight management and medical management. Advise patient to avoid alcohol or other CNS depressant drugs during and for 37 days after therapy has been discontinued. Advise patient, family and caregivers to look for suicidality, especially during early therapy or dose changes. Albuterol: Shake inhaler well, and allow at least 1 min between inhalations of aerosol medication. Prime the inhaler before first use by releasing 4 test sprays into the air away from the face. Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain. Instruct patient to prime unit with 4 sprays before using and to discard canister after 200 sprays. Actuators should not be changed among products. Advise patient to consult health care professional before taking any OTC medications, natural/herbal products, or alcohol concurrently with this therapy. Caution patient also to avoid smoking and other respiratory irritants. Inform patient that albuterol may cause an unusual or bad taste. Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth. Instruct patient to notify health care professional if no response to the usual dose of albuterol or if contents of one canister are used in less than 2 weeks.

NR292 Case Study 1 campus.docx

New 8/9/2011 rc