Nursing Case Study: Analysis of Ms. Tong's Medications, HNN215

This nursing case study focuses on Ms. Candice Tong, a 56-year-old patient admitted to the hospital with peptic ulcers caused by Helicobacter pylori. The paper analyzes Ms. Tong's medication regimen, including clarithromycin, amoxicillin, and esomeprazole, highlighting potential side effects such as stomach pain, acidity, and increased heart rate. It explores nursing interventions for managing these side effects, such as music therapy, post-meal medication administration, and blood pressure monitoring. The case study also examines the risks associated with ibuprofen and St. John's Wort in relation to Ms. Tong's condition and emphasizes the importance of educating patients about over-the-counter (OTC) medications, including their potential side effects, the use of checklists, and the role of pharmacists. The paper concludes with a discussion of the nursing care plan to improve patient outcomes and health literacy about OTC medications.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
The following nursing paper is based on the analysis of the case study of Ms Candice
Tong. The patient was admitted to Deakin Hospital on 14th of July 2019 with complains of
pain in the upper part of the abdomen along with vomiting and nausea. The result of
endoscopy and biopsy highlighted that she is suffering from peptic ulcer caused by bacteria
Helicobacter pylori (H.pylori). On next day, post her admission, her discharge planning was
done along with proper medication management planning. The aim of this paper is to
highlight prospective side-effects of the medications that are being prescribed for Mr Candice
Tong. The paper will also illustrated the effective management of those side-effects by
nursing intervention and education of the patient in the domain of over-the-counter (OTC)
medication.
Answer 1
Ms Candice Tong medication list contains Clarithromycin orally, twice daily for a
week. It is an antibiotic that is used for control the infection of H. Pylori (Vernon, 2019).
Clarithromycin is macrolide and nevirapine in nature. It main mode of action is driven
through non-nucleoside reverse transcriptase inhibitor and subsequent killing of the bacterial
cells. However, clarithromycin is associated with side-effects like increase in the level of
stomach pain along with indigestion, diarrhoea along with stomach bloating. Under extreme
scenario, the prolong use of these antibiotic causes unbearable pain in the stomach with high
pain score long with increase in the heart rate (Lanas & Chan, 2017). Taking into the age and
the pathophysiological condition of Ms Tong, it can be said that she is already diagnosed with
bacteria mediated peptic ulcer, encountering pain in the stomach can be detrimental as it can
hamper her overall quality of life. Clarithromycin also hampers the secretion of gastric acid
in the stomach and thus leading to acid accumulation hydrochloric acid (HCL) in the

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abdominal lumen and causing acidity. The medication chart of Ms Tong however contains
has medication of hypertension like felodipine and atorvastatin and but have no specific
medication for the management of pain and control of acidity. Thus increase in acidity in the
stomach further increases the level of pain along with the severity of developing gastric ulcer
(Vernon, 2019)
Konrad et al. (2018) are of the opinion that amoxicillin-clavulanic acid treatment
induce several side effects to the patient especially of the patient is an older adult or a
children and is on multidrug treatment. Ms. Tong is 56 years old and is on multidrug
treatment like amoxicillin, clarithromycin and esomeprazole. Thus development of adverse
symptoms is common in case of Ms Tong. The frequently encountered side-effect of Ms.
Tong will include development of stomach pain. Amoxicillin works by killing of the bacterial
(by inhibiting cell-wall biosynthesis) present in the stomach that is causing peptic ulcers.
High and regular dosage of amoxicillin (for Ms Tong it is 1 gram of amoxicillin per day for 7
days orally) can hamper the gastric acid section in the stomach leading to the increase in the
stomach pain. It also leads to the development of nausea and vomiting. Ms Tong is however,
have a medication for the management of vomiting and nausea, metoclopramide (Vernon,
2019).
Answer 2
The first risk of Mr Tong is increase in the level of stomach pain along with acidity in
the stomach. However, Thung et al. (2016) are of the opinion that with the increase in the
evolution of the multi-drug resistant Helicobacter pylori, multidrug treatment approach is
inevitable for successful eradication of the bacterial colonies within the stomach. Thus in
order to cope with the level stomach pain and acid formation in the stomach, proper nursing
intervention can be effective. First intervention includes application of music therapy for non-

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pharmacological management of pain. Krishnaswamy and Nair (2016) stated that application
of person-centred music therapy helps in distraction of the mood and thus helping to reduce
the sensation of pain. The second nursing intervention for the management of acid formation
in the stomach includes giving the medication post meal. Post meal administration of
medication decreases the risk of gastric acid accumulation in the stomach in comparison to
the medication given in empty stomach before meal (Mauldin 2017). Proper planning of the
diet chart of Ms Tong in the presence of professional dietician can also prove to be helpful in
reducing the chances of accumulation of gastric acid in the stomach. Mauldin (2017) stated
that maintaining a cyclic menu and having small meals within the duration of two hours can
help to reduce the chances of gastric acid accumulation in the stomach.
Another risk factor for Ms Tong is increase in the heart rate under the action of
Clarithromycin. According to Nursing and the Midwifery Board of Australia (NMBA)
(2016), Professional Code of Conduct, it is the responsibility of the nursing professional to
use critical thinking skill during implementation of the nursing practice (standard 1). And to
conduct comprehensive assessment before therapy implementation (standard 4) in order to
increase the provision of safe and effective care (standard 6). Thus in accordance with these
prevailing nursing standards, it would be the duty of the attending nurse to monitor the blood
pressure of Ms Tong and manage the dosage and the administration of the anti-hypertensive
pills accordingly. Drop in the blood pressure needs to reported at once to the doctor in order
to take further measures. Regulation of the salt intake can also be used as a means of non-
pharmacological management of the blood pressure (Graudal, Hubeck‐Graudal & Jurgens,
2017).

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Answer 3a.
Significant risk of Ibuprofen is development of peptic ulcers. Ms. Tong is already
suffering from severe peptic ulcer and the use of Ibuprofen can result in severe adverse
effects. Ibuprofen belongs to the class of non-steroidal anti-inflammatory drugs (NSAIDs)
and is used for pain management. Ms Tong was using this medication for managing her
headache. The study conducted by Drini stated that two risk of stomach ulcer formation is H.
Pylori and over use of NSAIDs. NSAIDs inhibit the synthesis of prostanoid and thus creating
barrier for conversion of arachidonic acids into prostraglandins or leukotrines by cyclo-
oxygenase enzyme (COX). Inhibition of COX enzyme in the gastro-intestinal tract decreases
the synthesis of prostaglandins causing development of gastric mucosa along with the
formation of musical injury. Mucosal injury leads to the inflammation in the gastric lining of
the stomach and thus causing peptic ulcer (Drini, 2017). Patients having H.pylori infection
are susceptible towards developing gastric ulcer like Ms Tong.
St John’s Wort is a herbal medication extracted from medical plant called Hypericum
perforatum. Booker et al. (2018) sated that it is used for the management of depression and
other complex mental health condition. St John's wort can leads to the development
photosensitivity of fluoroquinolone and tetracycline or other antibiotics. Thus there are
possible chances of cross-activity of this herbal medication with antibiotics leading to
detrimental side-effects. Ms. Tong is taking St John’s Wort as medication chart indicates that
she has depression and she herself reports that she feels flat in the domain of mood
management. In case Ms Tong, inactivity of antibiotics will lead in the generation of
multidrug resistant bacteria (H.pylori) (Thung et al., 2016).
Answer 3b.
1. Educating the patient about the use of OTC medication

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In this domain, I will focus on the common OTC medications like the once used as pin
reliever and over the counter medication and how it is harmful for the overall nervous
functioning of the body and the hepatic system. Food and Drug Administration [FDA] USA,
(2019) stated that over use of the OTC medication give rise to complications in the hepatic
cells. The damage in the hepatic less create disequilibrium in the lipid and fat metabolism and
at the same time hampers the process of glucose absorption and digestion. Since Ms Tong is
suffering from peptic ulcers, liver damage or malfunction of the liver can hamper the overall
digestive system of the body. Hamper in the digestive functioning of the body causes
indigestion, constipation or tendency of vomiting and diarrhoea (FDA, 2019). Healthy
literacy about the harmful side-effects of NSIADs might help Ms Tong to refrain from the
over use of the OTC pain killers (NSAIDs).
2. Educating about the checklist of OTC medication
I will also educate Ms Tong about the FDA approved checklist of the OTC
medication. According to the checklist of FDA, the a detailed information in the domain of
weight, age, allergies, gender, predisposition of other non-communicable disease and list of
other medications must be taken under consideration before buying and administering OTC
medication. Though Ms Tong is under anti-depressive pills,, she takes St. Johns’ Wort for her
mood elevation. Perrot et al. (2019) stated that for process of taking herbal medications in the
form of OTC medication might hamper the normal functioning of the anti-depressive pill0
and thus hampering normal neuro-pathological mechanism. . Thus she will be first educated
about the side-effects of the herbal OTC medications used for anti-depression. This will be
followed educating Ms Tong regarding how to prepare and follow the checklist before
purchasing OTC medication. The checklist also contains warning signs regarding when to
call doctor.

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3. Educating the patient about role of pharmacist in OTC medications
Since doctors do not prescribe OTC medications, the role of the pharmacist becomes
important while giving patient OTC medication (Perrot et al., 2019). Thus I will educate Ms
Tong regarding role of pharmacist in the OTC medication. I will also encourage Ms Tong to
actively seek help from a trained yet experienced professional pharmacist to avoid unwanted
complications during the consumption of OTC medication.
Conclusion
Thus from the above discussion it can be stated that long term use of antibiotic might
lead to gastro-intestinal problems. The conditions are vulnerable for patients with peptic
ulcers. Proper nursing care plan will help patient to recover from depressed mental state and
sensation of pain to body. However, over use of OTC medication might impose several
health threats. Health literacy about OTC medication will help to reduce the over us of OTC
medication.

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References
Drini, M. (2017). Peptic ulcer disease and non-steroidal anti-inflammatory drugs. Australian
prescriber, 40(3), 91.
Food and Drug Administration UK. 2019. Educational Resources: Understanding Over-the-
Counter Medicine. Access date: 14th August 2019. Retrieved from:
https://www.fda.gov/drugs/understanding-over-counter-medicines/educational-
resources-understanding-over-counter-medicine#articles
Graudal, N. A., Hubeck‐Graudal, T., & Jurgens, G. (2017). Effects of low sodium diet versus
high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol,
and triglyceride. Cochrane Database of Systematic Reviews, (4).
Konrad, P., Chojnacki, J., Gąsiorowska, A., Rudnicki, C., Kaczka, A., & Chojnacki, C.
(2018). Therapeutic efficacy of amoxicillin and rifaximin in patients with small
intestinal bacterial overgrowth and Helicobacter pylori infection. Przeglad
gastroenterologiczny, 13(3), 213.
Krishnaswamy, P., & Nair, S. (2016). Effect of music therapy on pain and anxiety levels of
cancer patients: A pilot study. Indian journal of palliative care, 22(3), 307.
Lanas, A., & Chan, F. K. (2017). Peptic ulcer disease. The Lancet, 390(10094), 613-624.
Mauldin, K. (2017). Nutrition Alterations and Management. Critical Care Nursing-E-Book:
Diagnosis and Management, 88.
Nursing and the Midwifery Board of Australia (NMBA) (2016). Professional Code of
Conduct. Access date: 9th August 2019. Retrieved from:

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https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
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Perrot, S., Cittée, J., Louis, P., Quentin, B., Robert, C., Milon, J. Y., ... & Baumelou, A.
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