Quality Use of Medicines Assignment: A Case Study

This case study discusses the quality use of medicines for Ms. Tong, who is on medication for stomach ulcers caused by the bacterium, Helicobacter pylori. The study assesses Ms. Tong’s medication chart and identifies two significant risks associated with the use of these medicines. It also describes the strategies a nurse may implement to prevent/manage the risks identified. The study further identifies and describes one significant risk that each of the medications ibuprofen and St John’s wort may contribute to when used in combination with Ms. Tong’s currently prescribed medication. Lastly, the study identifies and explains three key points for education that will be provided to Ms. Tong in relation to the general use of over-the-counter medications prior to her discharge.

Running Head: QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
Q1. Assess Ms Tong’s medication chart and identify and explain two (2) significant risks
that may be associated with the use of these medicines.
From the medication chart, Ms. Tong’s doctor has prescribed clarithromycin, esomeprazole, and
amoxicillin, to be taken as a regular medication. Besides, the doctor prescribed Metoclopramide,
to be taken as a “pro re nata” (PRN) medication. Clarithromycin and amoxicillin are antibiotics
administered to counter bacterial infections. On the other hand, esomeprazole (a proton-pump
inhibitor), is administered to reduce the amount of acid produced in the stomach. A combination
of these three drugs is administered to treat stomach ulcers that are caused by the
bacterium, Helicobacter pylori.
Metoclopramide interacts with an antidepressant such as sertraline. Antidepressants target the
serotonin transporter, resulting in either serotonin syndrome-like events, or dystonia. The
interaction causes the overstimulation of both the central and peripheral serotonin receptors
(Diaz et al., 2018). Serotonin is a hormone produced in the body that helps with sleeping,
digestion, and regulation of mood. Serotonin syndrome results from an increase in the production
of serotonin, and inhibition of the hormone’s reuptake and metabolism. Serotonin syndrome is
characterized by the rapid development of hyperthermia, high blood pressure, a change in the
mental status, for instance, one becomes delirious, autonomic instability, stiffness, vomiting,
diarrhea, nausea stomach cramp, and muscle twitches.
Metoclopramide has also been associated with mental depression in patients with and those
without any previous history of depression (Igata et al., 2016). Patients on Metoclopramide have
demonstrated depression symptoms, ranging from mild to severe, such as continuous sadness,
feelings of hopelessness, and helplessness, feelings of guilt, irritation and a lack of tolerance to

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
other people, having no interest in the occurrences around them, increase in anxiety, developing
thoughts of self-harm, and even attempting to commit suicide. Ms. Tong is on treatments for
depression. Administration of Metoclopramide to this patient will lead to her developing a severe
form of depression. Ms. Tong, as a consequence, has an increased likelihood of developing
bipolar disorder. The extreme shifts in mood and variations in the levels of energy and normal
functioning of the body may be detrimental to her health, which may lead to the deterioration of
her health (Harada et al., 2017). Fluctuations in the mood that is associated with bipolar will
adversely affect Ms. Tong’s response to the medication. It will delay the rate of elimination of H.
pylori. It will also cause the progression of her ulcers, leading to extreme discomfort
Q2. Describe the strategies a nurse may implement to prevent/manage the risks identified
in Question 1.
The development of serotonin syndrome can be recognized and prevented before it develops to
extreme levels. A nurse can apply several strategies to ensure that serotonin syndrome does not
develop during Ms. Tong’s treatment. The nurse can minimize the amount of Metoclopramide
being administered to the patient. Metoclopramide is usually prescribed to relieve the feelings of
nausea, vomiting, heartburn, loss of appetite, and the feeling being full after eating. A lower dose
of Metoclopramide will reduce the chances of drug-drug interactions with any antidepressant
medication available in Ms. Tong’s bloodstream. The nurse can also discontinue the
administration of Metoclopramide. While the patient patient’s comfort will have been greatly
affected, the chances of developing serotonin syndrome will have been avoided entirely, “since
many cases of the syndrome are self-limiting if medications are stopped early.” (Christopher
Frank, 2008).

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
If the comfort of the patient is given priority, and Metoclopramide has to be administered, the
nurse can continuously monitor the patient to detect any signs of development of serotonin
syndrome. The nurse can counter hyperthermia by cooling the patient externally, hydration, and
administration of benzodiazepines, such as diazepam. Benzodiazepines are thought to also
reverse neurological symptoms such as myoclonus and hyperreflexia (Grenha et al., 2013)
According to a study conducted by Bruce et al., (2011), depression affects medical care
negatively, and measures to prevent its occurrence must be taken while giving medical care. To
minimize the chances of Ms. Tong to become more depressed, and therefore prevent her from
developing bipolar disorder, the nurse in charge can withdraw Metoclopramide which has been
shown affect serotonergic receptors, and thus cause depression. The nurse can also reduce the
risk of development of depression by ensuring that the patient is satisfied and happy. The nurse
must make sure that the patient’s comfort is not tampered with so that the patient can be
continuously in high spirits. Furthermore, the nurse can, with as much patience as possible,
explain to the patient the care being given and why. They should educate the patient on their
illness, and the medication being used to remedy it. Besides, the nurse may minimize the risk of
depression, by sensitizing the patient on their increased possibility of being depressed due to the
medication be used, and reassure her that she (the patient) is in the best care and that she will be
getting better soon. The nurse can also urge Ms. Tong’s relatives to take part in her treatment and
educating them on how to take care of her after she is discharged.

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
Q3a. When you assist Ms Tong to find fresh clothes, you notice that there are bottles of the
medications ibuprofen and St John’s wort in her bag. These medications are easily
purchased from pharmacies and supermarkets. Ms Tong informs you that she takes one of
these medications for headaches, and the other because she feels “flat.” Identify and
describe one (1) significant risk that each of these medications may contribute to when used
in combination with Ms Tong’s currently prescribed medication
Ibuprofen is an example of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), which is used to
relieve pain from various conditions such as headache, dental pain, menstrual cramps, muscle
aches, arthritis, etc. (Solomon et al., 2017). NSAIDs are however associated with inflammation
of the stomach lining, which results in the erosion of the mucosa membrane, and adversely affect
metabolic processes, such as digestion, and absorption of nutrients in the stomach. The use of
NSAIDs is, therefore, contraindicated in patients with ulcers. Ibuprofen counters the action of
esomeprazole. It inhibits the secretion of prostaglandin, and thus its protective effects in gastric
mucosa. The risk increases with increase in age, and history peptic ulcers, heart diseases,
corticosteroids, etc. which leads to excessive bleeding and discomfort.
St John’s Wort ( Hypericum perforatum), is a plant used for the treatment of depression. It is
thought that it contains an ingredient, hypericum, which inhibits the uptake of serotonin,
noradrenaline, and dopamine. Being a herbal remedy (Velinger, Gupta, and Hegde, 2017), St
John’s Wort has an increased chance of causing adverse effects, since it is unpurified. Risk of
poisoning is also heightened by the fact that the drug is self-prescribed. The most commonly
reported adverse reactions for the drug are gastrointestinal symptoms, allergic reactions,
dizziness/confusion, tiredness/sedation, and dry mouth. Research has shown that St John’s Wort
contains ingredients which a number of enzymes involved in the metabolism of drugs

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
(Henderson et al., 2002). When taken alongside Ms. Tong’s prescription, there is a likelihood of
inducing the degradation of the medication, before it can eradicate the H. pylori, which will
delay the healing process. St. John’s Wort can also interact with Metoclopramide (Baxter and
Sharp, 2008), which leads to the stimulation of serotonergic receptors, which results in serotonin
syndrome that adversely affects the action of the administered drugs.
Q3b. Identify and explain three (3) key points for education you will provide Ms Tong in
relation to the general use of over-the-counter medications prior to Ms Tong’s discharge.
Over the counter drugs are sold to patients without the need for a prescription from a healthcare
professional. Ms. Tong will be required to purchase some dugs from the chemist as a result of
her condition, and therefore, she needs to be educated on the proper use of these drugs. Many
elderly patients are faced with the challenge of medication mismanagement, contributed by both
environmental and human factors. Better communication between health care professionals and
patients helps to mitigate this problem by promoting proper self-management of medications. I
will educate Ms. Tong on better usage of OTC drugs that she will purchase. First, I will take her
through on how to store these drugs properly to avoid contamination (Akici, 2018). She needs to
keep the medications in a place that is dry and cool. For instance, in the kitchen cabinet and away
from any hot appliances like sink and stove. Also, she can store the drugs on a shelf, in a closet
or inside a storage box. The bathroom cabinet can also be an excellent place to store her
medicines, just like most individuals do. There is a need for her to keep the drugs away from
sunlight and in an area that is inaccessible by a child.
The next thing that I will inform her about is on the need to follow the correct dosage while
undertaking her medication. She should follow all the instructions given to her without omitting
or ignoring any dosage instruction; however insignificant it may seem to be. Taking medicines as

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
prescribed by a health professional is advantageous to a patient as he or she can get maximum
assistance from the drugs. An individual is also able to improve on his or her chances of
achieving a better health outcome (Peck, 2016).
Additionally, I will point out to Ms. Tong on the importance of using the right equipment while
taking her medication. She should not use everyday kitchen utensils such as teaspoons to
undertake oral drugs. Such utensils have a high probability of being contaminated which
increases one’s risk of acquiring further infections, especially if they are not hygienically
cleaned. Also, household spoons do not measure the right dosage accurately leading to a patient
to take the incorrect dosage. Therefore, she should use a properly cleaned and dried medicine
spoon to take her oral liquid medicine (Zelikin, 2016). It is crucial for Ms. Tong to review her
medications with a medical professional regularly as it will aid in her recovery.

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
References
Baxter Karen, and Sharp Jennifer. (2008). Drug interactions that can occur with St John’s
wort. The Pharmaceutical Journal.
Henderson, L., Yue, Q. Y., Bergquist, C., Gerden, B., & Arlett, P. (2002). St John’s wort
(Hypericum perforatum): drug interactions and clinical outcomes. British journal of clinical
pharmacology, 54(4), 349-35
Grenha, J., Garrido, A., Brito, H., Oliveira, M. J., & Santos, F. (2013). Serotonin syndrome after
sertraline overdose in a child: a case report. Case reports in pediatrics, 2013.
Frank, C. (2008). Recognition and treatment of serotonin syndrome. Canadian Family
Physician, 54(7), 988-992.
Diaz, D., Vallejos, Á., Torres, S., Hernández, W., Calvache, J., Merchán, J., ... & Maldonado, L.
(2018). Detection of potential risks in the prescription of tricyclic antidepressants through an
online clinical alert system. Revista Colombiana de Psiquiatría.
Igata, R., Hori, H., Atake, K., Katsuki, A., & Nakamura, J. (2016). Adding Metoclopramide to
paroxetine induced extrapyramidal symptoms and hyperprolactinemia in a depressed woman: a
case report. Neuropsychiatric disease and treatment, 12, 2279
Harada, T., Hirosawa, T., Morinaga, K., & Shimizu, T. (2017). Metoclopramide-induced
Serotonin Syndrome. Internal Medicine, 56(6), 737-739.
Solomon, D. H., Husni, M. E., Libby, P. A., Yeomans, N. D., Lincoff, A. M., Lϋscher, T. F., ...
& Borer, J. S. (2017). The risk of major NSAID toxicity with celecoxib, ibuprofen, or naproxen:
a secondary analysis of the PRECISION trial. The American journal of medicine, 130(12), 1415-
1422.

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QUALITY USE OF MEDICINES ASSIGNMENT: A CASE STUDY.
Velingkar, V. S., Gupta, G. L., & Hegde, N. B. (2017). A current update on phytochemistry,
pharmacology and herb–drug interactions of Hypericum perforatum. Phytochemistry
Reviews, 16(4), 725-744.
Akici, A., Aydin, V., & Kiroglu, A. (2018). Assessment of the association between drug disposal
practices and drug use and storage behaviors. Saudi Pharmaceutical Journal, 26(1), 7-13.
Peck, R. W. (2016). The right dose for every patient: a key step for precision medicine. Nat Rev
Drug Discov, 15(3), 145-146.
Zelikin, A. N., Ehrhardt, C., & Healy, A. M. (2016). Materials and methods for delivery of
biological drugs. Nature chemistry, 8(11), 997.
Rainsford, K. D. (2013). Ibuprofen: pharmacology, therapeutics and side effects. Springer
Science & Business Media.
Laine, L., & Jensen, D. M. (2012). Management of patients with ulcer bleeding. The American
journal of gastroenterology, 107(3), 345.
Ng, Q. X., Venkatanarayanan, N., & Ho, C. Y. X. (2017). Clinical use of Hypericum perforatum
(St John’s wort) in depression: a meta-analysis. Journal of Affective Disorders, 210, 211-221.
Solomon, D., Adams, J., & Graves, N. (2013). Economic evaluation of St. John’s wort
(Hypericum perforatum) for the treatment of mild to moderate depression. Journal of affective
disorders, 148(2-3), 228-234.
Smith, B. W., Ortiz, J. A., Steffen, L. E., Tooley, E. M., Wiggins, K. T., Yeater, E. A., ... &
Bernard, M. L. (2011). Mindfulness is associated with fewer PTSD symptoms, depressive

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symptoms, physical symptoms, and alcohol problems in urban firefighters. Journal of
Consulting and Clinical Psychology, 79(5), 613.