Drug Monitoring & Complication Identification

This assignment provides details on therapeutic drug monitoring tests for several medications, including Ibuprofen (HPLC), Levofloxacin (Bioassay), Furosemide (Tandem Mass Spectrometry), Insulin therapy (C-peptide & glucose tests), and more. It also identifies three relevant complications for each diagnosis, such as dislocation, infection, and difficulty in breathing.

Personal practice
of case study

Table of Contents
A. Pathophysiology of each primary diagnosis...........................................................................3
B. Interventions and assessment of 27 patients .........................................................................7
C. Diagnosis of 27 patients.......................................................................................................12
D. What types of medications will be given to each diagnosis?...............................................15
E. What nursing care should be provided when certain medications are given?......................16
F. What pathology/laboratory test results should be monitored and checked when certain
medications are given?..............................................................................................................19
G. Identify three most relevant complications of each diagnosis?............................................19

A. Pathophysiology of each primary diagnosis
1. THR d/t recurrent dislocation-
 Humerus separates from scapula
2. Pneumonia Pathogen reaches alveoli Inflammation of air sacs
3.Fall-Not coping Risk factors provide opportunity to fall Age-associated changes in strength and balance
4. COPD- Production of more mucus Inflammation of bronchioles and their subsequent narrowing Less oxygen reaches capillaries Exhalation of less carbon dioxide
5. Diabetic ketoacidosis Blood Tests ·Insulin deficiency Increase in counter regulatory hormone Hormonal imbalance leading to hepatic glucogenesis and lipolysis Hyperglycemia Accumulation of acidic intermediates and end metabolites. Ketones overflow in urine when they exceed the body’s capacity to extract Chest X-ray
6. Functional decline:
 Changes at the tissue level is identified
 Chronic low-grade inflammatory activity
 Malnutrition,aging and immobilization
7. Diarrhoea: Increase in the volume stool gastrointestinal disease reflect primary disorders increase use of methotrexate
1

Raynaud's disease:
 Intense vasospasm with associated color change Most susceptible to cold injury. Commonly affect nose,toes and ears.
8. Scleroderma Change in the expression of DNA and micrRNA. Severe fibroproliferative vascular lesions of small arteries Alterations of humoral and cellular immunity.
9. COP:Influenza: Chronic inflammation of the airways,lung tissues Causes inflammatory cells such as neutrophilis ,B-cells. Lead to damage of tissues and a range of other effects.
Influenza: All avian influnza infections Hemagglutinin and neuraminidase are crtical for virulence Allowing cellular infections
10. Pneumonia: Causes for pneumonia can be intrinsic or extrinsic
 Exposure to causative agent,pulmonary irritants etc. Altered mental status due to intoxization
11. Hypercholestrolaemia: Consequences of abnormal lipoprotein metabolism Reduction of LDL receptor expression or activities Risk factor for the development of atherosclerosis.
12. Type 2 diabetes mellitus: Heterogeneous disorder Insulin resistance
 Imapired regulation of hepatic glucose production declining b-cell
13. Acute haemorrhagic stroke: Occurrence of bleeding directly into the brain parenchyma
2

 Leakages from small intracerbral arteries damaged by chronic hypertension Cerebral amyloidosis and cocain abuse
14. Glaucoma: Level of intraocular pressure is related to retinal ganglion cell death Determination of intra-ocular pressure Increased resistance to aqueous outflow
15. Delirium: Based on level of psychomotor activity hyperactive delirium is observed Present with lethargy,drowsiness ,apathy
16. Dysphagia: Associated with respiratory disorder Increased risk of aspiration pneumonia.
17. NSTEMI (Non ST segment elevation myocardial infraction): A persistent occlusion of a large epicardial cronary artery risk to area of myocardium and severe chest pain
18. EXAC COPD: Increase number of macrophages and CD8 T lymphocytes Viral and bacterial infections
19. Type 2 diabetes mellitus: Heterogeneous disorder Insulin resistance
 Impaired regulation of hepatic glucose production declining b-cell
20. COAD: Mantle Cell Lymphoma: Lymphoproliferative disorder
 Associated with chromosome translocation . Involvement of immunoglobulin heavy chain gene.
21. Mantle Cell Lymphoma: Lymphoproliferative disorder Associated with chromosome translocation .
3

 Involvement of immunoglobulin heavy chain gene.
22. Decompensated cardiac failure: Not copying
23. Delirium: Based on level of psychomotor activity
 hyperactive delirium is observed Present with lethargy,drowsiness ,apathy
24. Influenza A: All avian influnza infections
 Hemagglutinin and neuraminidase are crtical for virulence Allowing cellular infections
25. Pneumonia: Causes for pneumonia can be intrinsic or extrinsic Exposure to causative agent,pulmonary irritants etc.
26. EXAC COPD: Increase number of macrophages and CD8 T lymphocytes Viral and bacterial infections
27.Nausea : A threshold for nausea Depends on the interaction of certain factors Stimuli giving rise to nausea
4

B. Interventions and assessment of 27 patients
 THR d/t recurrent dislocation-
Immobilization
Surgery
Rehabilitation
Assessment: THR d/t recurrent dislocation includes pain and slipping. Along with this all the
movements are resisted. It looks like separated and d-located from its axis.
 Pneumonia
Antibiotics
oxygen therapy
Assessment: In order to assess pneumonia various diagnosis’s are considered such as
radiography, along with this breath temperature increased, nasal flaring and cyanosis, etc.
 Fall-
Plaster
Surgery
Assessment: The analysis is based on the injury caused due to falling of the individual.
 COPD-
Pulmonary rehabilitation
Guided muscle relaxation
Assessment: The assessment process in which physical and mental activities of the individuals
are considered for analyzing their ability and on the basis of that fall risk factors are assessed.
 Diabetic ketoacidosis
Fluid replacement
Electrolyte replacement
Insulin therapy
Assessment: In order to assess the Diabetic ketoacidosis, blood and urine sugar level is analyses.
Along with this energy generated by break down fats are also analysed.
 Functional decline:
Plaster
Surgery
5

Assessment: The functionality status of the individual helps the doctors in order to analyse the
medical condition of the individual, on the basis of their mobility their condition is analysed.
 Diarrhoea:
Oral re hydration therapy
Anti-motility medications
Assessment: For evaluation of diarrhea various factors are included such as respiratory rate,
oxygen saturation, body temperature, pulse rate, etc.
 Raynaud's disease:
Sympathectomy
Assessment: The assessment of raynaud's disease is based on the color of the figures. The
discolored figures refers that individual is suffering from the disease.
 Scleroderma:
Acupuncture
Chinese treatment
Assessment: In order to detect scleroderma, various body parts are analysed, along with this
immune system is also evaluated on the basis of that antibodies are provided.
 COP:
COP 1 therapy
Multi myeloma therapeutic strategy
Assessment: The COP 1 therapy analysis is done through radiography, along with this breath
temperature increased.
 Influenza:
Gene therapy
Antiviral therapy
Assessment: The influenza analysis s based on various factors such as throat, nose, lungs, along
with this diarrhea and vomiting also happens to the individual.
 Pneumonia:
Empiric antibiotic therapy
Fluid resuscitation
Assessment: In order to assess pneumonia various diagnosis’s are considered such as
radiography, along with this breath temperature increased, nasal flaring and cyanosis, etc.
6

 Hypercholestrolaemia:
LDL apheresis
LDLr gene transfer therapy
Assessment:A physical examination to detect the cause of symptoms of stroke.
 Type 2 diabetes mellitus:
Insulin therapy
SGLT 2 Therapeutic
Assessment:Using a physical exam and few tests it can be diagnosed.
 Acute hemorrhagic stroke:
Physical therapy
Surgical treatment
Assessment:A physical examination to detect the cause of symptoms of stroke.
 Glaucoma:
Laser therapy
Micro invasive surgery
Assessment:Using a physical exam and few tests it can be diagnosed.
 Delirium:
Medications
Managing behaviours
Assessment: A validated tools such as Confusion Method for the ICU can be used for assessment. Monitoring lab test
 Dysphagia:
Electrical stimulation
Oral motor therapy
Assessment: Diagnosis of swallowing disorder Assessment of swallowing
 Physical examination
 NSTEMI (Non ST segment elevation myocardial infraction):
Bypass graft surgery
7

Angioplasty surgery
Assessment:History and physical examination
 EXAC COPD:
Physiotherapy
Oxygen supplementation
Insulin therapy
SGLT 2 Therapeutic
Assessment: proper diagnosis been done. Physical examinations Patient history.
 COAD:
Lungs volume reduction surgery
Salt therapy
Stem cell therapy
Assessment: Evaluation of defects Things that need to be inquired History of patients
 Mantle Cell Lymphoma:
Radiation therapy
Mantle cell lymphoma rituximab maintenance therapy
Assessment: Evaluation of defects Things that need to be inquired History of patients
 Decompensated cardiac failure:
Bypass graft surgery
Angioplasty surgery
Assessment:Past History
 Delirium:
Medications
8

Managing behaviours
Assessment: Physical examination Monitoring lab test
 Influenza A:
Neuraminidase inhibitors treatment
Assessment: Evaluation of defects Things that need to be inquired History of patients
 Pneumonia:
Empiric antibiotic therapy
Fluid resuscitation
 EXAC COPD:
Physiotherapy
Oxygen supplementation
Assessment:Review the result of pulmonary tests
 Nausea:
Radiation therapy
Hormone replacement therapy
Assessment: Examine the mouth and pharynx Examine the abdomen
 Undertake neurological examination
9

C. Diagnosis of 27 patients
1. THR d/t recurrent dislocation- Shoulder examination test-This test will examine any dislocation in the shoulder.
2. Pneumonia
 Blood test – It will recognize any type of organism that cause infections
 Chest X-ray- The extent and location of the infection will be determined.
3. Fall-
 The chair rising test
 Both prevention and thready must be focused
4. COPD-
 Pulmonary function tests
 Spirometry
5. Diabetic ketoacidosis
 Blood Tests Chest X-ray
6. Functional decline:
 Chest X-ray
7. Diarrhoea:
 Stool Test Blood Test
8. Scleroderma Blood Test -In order to check the elevated blood levels Breathing tests A CT scan of lungs
9. COP:Influenza: Influenza testing
10. Pneumonia: Blood test – It will recognize any type of organism that cause infections Chest X-ray- The extent and location of the infection will be determined.
11. Hypercholestrolaemia: Blood test known as Lipoprotein protein is used
12. Type 2 diabetes mellitus: A fasting plasma glucose level A 2 hour plasma glucose level of 200 mg/dl
13. Acute haemorrhagic stroke: Blood tests
10

 Brain MRI
14. Glaucoma: Eye pressure test Visual field test
15. Delirium: Blood and Urine Test Physical examination
16. Dysphagia: X-ray with contrast material A visual study of esophagus Esophageal muscle test
17. NSTEMI (Non ST segment elevation myocardial infraction): History and physical examination A chest radiograph
18. EXAC COPD: A chest X-ray
19. Type 2 diabetes mellitus: A fasting plasma glucose level A 2 hour plasma glucose level of 200 mg/dl
20. COAD: Spiromtery test Chest x-ray disease Arterial blood gas test
21. Mantle Cell Lymphoma: Blood test Bone marrow biopsy Computed axial tomography
22. Decompensated cardiac failure: Blood test Past History
23. Delirium: Blood and Urine test Physical examination
24. Influenza A:
11

 Use an influenza test
25. Pneumonia: Blood test – It will recognize any type of organism that cause infections Chest X-ray- The extent and location of the infection will be determined.
26. EXAC COPD:
 Pulmonary function tests Spirometry
27.Nausea :
 CT/MRI
12

D. What types of medications will be given to each diagnosis?
Following medications will be given for mentioned diagnosis: Recurrent dislocation: Ibuprofen and Ketoprofen. Pneumonia: Levofloxacin and amoxicillin-clavulanate and macrolide. Fall not coping: Paracetamol Pulmonary edema: Nitroglycerine and diuretics such as furosemide. Diabetic ketoacidosis: Insulin therapy. Functional decline: Selective serotonin-reuptake inhibitor (SSRI) medication. Diarrhoea: antidiarrhoeal medicines which includes loper-amide and bismuth
subsalicylate. Raynaud's disease: Nifedipine. Scleroderma: Epoprostenol. COP: Corticosteroid such as prednisone. Influenza: Relenza and Rapivab. Pneumonia: [refer to patient 2.] Delirium: antipsychotic such as Haloperidol. Hypercholestrolaemia: Lovastatin and Pravastatin. Type 2 diabetes mellitus: Metformin and Sulpfonylureas. Acute haemorrhagic stroke: Anticonvulsants Glaucoma: Xalatin. Delirium: [refer to patient 10] Pneumonia: [refer to patient 2] Dysphagia: Lansoprazole. NSTEMI (Non ST segment elevation myocardial infraction): Morphine and Nitrates EXAC COPD: Corticosteroid and bronchodilators. Type 2 diabetes mellitus: [refer to patient 12]. COAD: Aclidinium and formoterol. Mantle Cell Lymphoma: Cyclophosphamide. Decompensated cardiac failure: Vasodilators such as nesiritide, inodolators such as
milrinone. Delirium: [refer to patient 10] Influenza A: [refer to patient 9] Pneumonia: [refer to patient 2] EXAC COPD: [refer to patient 18]
13

 Nausea: Meclizine and dimenhydrinate.
E. What nursing care should be provided when certain medications are given?
 Recurrent dislocation:
1. Ibuprofen: In acute pain only nurses should provide 200-400 mg/dose i.e. 1200 mg a
day.2. Ketoprofen: It can be given 590 mg orally 4 times in a day or 75 mg orally 3 times a day
do not exceed over 300 mg a day.
 Pneumonia:
3. Levofloxacin: Only given in case of infection 500 mg orally or intravenous once in a day
for 7-14 days.
4. Amoxicillin-clavulanate: Only given in case of severe in infection 250/125 mg orally in
every 8 hours for 10 days.5. Macrolide: In case of respiratory infection Normal doses 500 mg for 1 day and then 250
mg orally for 4 days.
 Fall not coping:14. Paracetamol: Nurses should only provide this medicine in case of sever pain with dose
ranging from 500 to 1000 mg every 6 hours.
 Pulmonary edema:
2. Nitroglycerine: Only used to when blood vessels are blocked with dose of 5 mcg/min
through continuous intravenous infusion.3. Furosemide: It is only administered on the first day with dose of 120 mg.
 Diabetic ketoacidosis:4. Insulin therapy: it is given only in the case of hypoglycaemia with dose of 0.3 units per
kg.
 Functional decline:5. Selective serotonin-reuptake inhibitor (SSRI) medication: It is only given to patient to
come up from depression. Fluoxetine can be given with the highest dose of 20 mg a day.
 Diarrhoea:
6. Loper-amide: To get cure from diarrhoea nurses should provide patients with 4 mg of
loper-amide after first stool and then 2 mg after each stool and exceeding from 16 mg a
day.
14

13. Bismuth subsalicylate: Only given in case if loper amide is not working effectively with
dose of 524 mg orally in every 30-60 minutes not more than 8 doses in 24 hours.
Raynaud's disease:14. Nifedipine: It is only used in severe cases to get reduction n blood pressure and is not
recommended as it causes several reactions.
 Scleroderma:15. Epoprostenol: Used for the treatment of scleroderma related digital vasculopathy with
dose of 2ng/kg/min and increased to 8ng/kg/min within 15 minutes.
 COP:12. Prednisone: It should be given by nurses only to decrease the body's immune system
with dose limit of 5-60 mg per day divided onto 2-4 intervals.
Influenza:13. Relenza: These medicines should not be given to patients having respiratory problems. Pneumonia:[refer to patient 2.]
Delirium:14. Haloperidol: Should be given to dementia patients to control their disruptive behaviour
with the dose of 0.5 to 2 mg 2-3 times orally in one day.
 Hypercholestrolaemia:15. Lovastatin: Nurses can use it as a therapy for dietary control and can provide patients
with dose of 20 mg/d.
 Type 2 diabetes mellitus:16. Metformin: It should be used only in case of increasing the tissue sensitivity for insulin
to use it more efficiently and reduce the glucose production in liver. It can be provided
with initial dose of 500-1000 mg orally once in a day.
 Acute haemorrhagic stroke:17. Anticonvulsants: It should be provided to suppress the rapid neuron firing during the
seizures.
 Glaucoma:18. Xalatin: It should be given only when the pressure is increased over the eyes to reduce
that pressure Delirium: [refer to patient 10]
15

Pneumonia:[refer to patient 2]
 Dysphagia:15. Lansoprazole: They can be used as the proton pump inhibitors.
 NSTEMI (Non ST segment elevation myocardial infraction): Morphine: It can be used in case of severe pain and can be provided with 5-30 mg dose
in every 3-4 hours.
 EXAC COPD: Corticosteroid: These medicines can only be used to treat the increased mucous
production. Type 2 diabetes mellitus: [refer to patient 12]
 COAD: Aclidinium: If shortness in breathing occurs then this medicine can be provided with
dose of 400 mcg twice a day.
 Mantle Cell Lymphoma: Cyclophosphamide: It can be used as chemotherapy drug in patients of MCL.
 Decompensated cardiac failure: Nesiritide: It can be used to relax the blood vessels in order to decrease the elevated
blood pressure and can be given intravenous with the dose of 2 mcg/kg. Delirium: [refer to patient 10] Influenza A: [refer to patient 9] Pneumonia:[refer to patient 2] EXAC COPD: [refer to patient 18]
 Nausea:
3. Meclizine: in case of severe vomits and nausea this tablet can be used with the dose
ranging from 25-50 mg a day.
F. What pathology/laboratory test results should be monitored and checked when certain
medications are given?
1. Ibuprofen: High performance liquid chromatography for therapeutic drug monitoring.
2. Levofloxacin: Levofloxacin level, Bioassay
4. Furosemide: Tender mass spectrometry for therapeutic drug monitoring.
5. Insulin therapy: C-peptide test and glucose tests
16

6. Fluoxetine: Fluoxetine measurement test
7. Nifedipine: Serum/Plasma test
9. Prednisone: Serum test
10. Haloperidol: Haloperidol serum test
12. Metformin: Quantitative high performance liquid chromatography serum and plasma
test
13. Anticonvulsants: Anti-Seizure Medications Blood Test
17. Morphine: Urine morphine measurement test
22. Nesiritide: Ames test
G. Identify three most relevant complications of each diagnosis?
17. Dislocation, graft fracture and arthrosis.
18. Infection in blood streams, organ failure and difficulty in breathing.
19. Physical injury, head injury and vision and hearing loss.
20. Difficulty in breathing, heart problems and cardiac arrest.
21. Severe dehydration, coma and swelling of brain.
22. Acceleration in bone loss, delirium and pressure ulcers.
23. a) nausea, vomiting and loss of fluid.
b) Skin ulcers, development of gangrene and blockage of arteries.
24. Damage in muscle tissues, problem in electrical conduction of heart and heart failure.
25. a) Lungs inflammation, obstruction of small airways and blockage of air sacs.
b) Pneumonia, dehydration and ear infection.
26. a) Refer to patient 2
b) Pressure ulcers, pulmonary emboli and decrease in oral intake.
27. Reduce flow of blood through arteries, chest pain and hear attack.
28. Hypoglycaemia, hyperosmolar hyperglycaemic nonketotic syndrome and heart disease.
29. Haemorrhagic stroke, hypertension and stroke complications.
30. Hyphema, visual loss and retinal detachment.
31. a) refer to patient 10
b) refer to patient 2
32. Pain in swallowing, drooling and frequent heartburn.
33. Chest pain, heart burn and feeling faint.
17

34. Pneumonia, polycythemia, and pneumothorax.
35. Refer to patient 12
36. Coughing, wheezing, and shortness of breath.
37. Swelling in lymph nodes, heart burn and night sweats.
38. Severe hypotension, acute headache and worsening in the renal function.
39. Refer to patient 10
40. Refer to patient 9
41. Refer to patient 2
42. Refer to patient 18
43. Dizziness, motion sickness and fainting.
18

Nursing Interventions
Interventions Rationales
The weight of patint need to be chancked daily
nad the decrese in weight need to be noted .
An important indicator of fluid balace in the
body is an accurate dailyweight.
A diary of patint need to be maintained that
19

20

21

2