Case Study: Medical Chart Analysis, Risks, and Nursing Strategies

This case study examines the medical chart of Mr. Laurent, who is suffering from various health issues including hypertension, diabetes, asthma, and hyperprolactinaemia. The assignment assesses the risks associated with his medications, such as hydrocortisone, atorvastatin, ceftriaxone, and erythromycin, detailing potential side effects like mood swings, muscle pain, and the risk of infections. It explores nursing strategies to mitigate these risks, including care plans, patient education, and dietary recommendations. The study also emphasizes safety measures to prevent medication errors, such as adherence to the five rights of medication administration, proper medication storage, and the use of drug guides. Furthermore, it discusses the benefits of intravenous (IV) erythromycin and ceftriaxone, highlighting their roles in treating bacterial infections and supporting overall health. The assignment concludes by summarizing the importance of comprehensive medical documentation and patient-centered care to ensure optimal patient outcomes. This case study provides valuable insights for healthcare professionals to enhance patient safety and improve treatment effectiveness.

CASE- STUDY

TABLE OF CONTENTS
Q.1 (A) Critical assessment of medical chart and risk associated with use of medicines......1
Q.1 (B) Use of nursing strategies to prevent risks..................................................................2
Q.2 Use of safety measures to prevent risk of medication errors...........................................3
Q.3 Benefits of regular consumption of intravenous (IV) erythromycin and ceftriaxone.....4
REFERENCES................................................................................................................................6

Q.1 (A) Critical assessment of medical chart and risk associated with use of medicines
Individuals are at risk of developing various type of diseases as per advancing age.
Common disorders may include hypertension, diabetes, heart-stroke, blood pressure, sleep
depressives, fatigue, anxiety and depression. These may be caused due to many factors which
may include personal, psychological or social elements. It lays a severe impact on the health and
well-being of an individual (Cudkowicz and et.al., (2014). This case study moves around
wellness of Mr. Laurent who is suffering from issues like fatigue, breathlessness etc. Report will
include nursing strategies which can be used to prevent risks which patient id developing.
Mr. Laurent's medical chart shows that patient is suffering from various type of diseases.
It has been noted that individual has been provided with 100 mg doses of hydrocortisone and
salbutamol. This is due to symptoms of asthma. Symptoms include shortness in breath or chest
pain. Study reveals that all the signs have been seen in service user. It is caused due to air
pollution, inhalation of dust particles and because of lack of physical activity. Medication chart
of person provides with data that, patient has been given Ceftriaxone and erythromycin 1 gm in
order to recover through chest infection (Das and et.al., 2015). Moreover, from the medical
history, it has been determined that occasionally Mr Laurent take Ventolin for Asthma. Mr.
Laurent has also been suffering from hypertension and for curing this specialist has intended user
to take periodontal arginine 5 mg on daily basis.
Propranolol 160 mg has also been suggested to be consumed by an individual. Wellness
chart of patient reveals that person is at risk of developing hyperprolactinaemia for which health-
care professionals has prescribed medicine atorvastatin 40 mg on regular ground. High blood
pressure raises in person because of the elements like stress or family history of hypertension,
genetics and older age (Tsujita and et.al., (2015). Chart of drugs also gives an image that patient
is suffering from type two diabetes. Medicine like met for min 850 mg and glargine insulin 10
units is consumed by Laurent. Study shows that weight of service user is 92 kilograms which is
one of the major cause of blood sugar. This disorder can also be caused due to physical inactivity
and overdose of certain drugs.
Significant risk
 Hydrocortisone is mainly given to patients suffering from asthma. There are some side
effects on use of this drug which can affect well-being of an individual. Regular
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consumption of this medicine can lead to various issues like mood swings, stomach ache,
vomiting, fever, anxiety, itching, weakness and back-pain (Komukai and et. al. (2014).
 Consumption of drugs like atorvastatin is a threat for a patient as it holds the risk of
developing diseases like high cholesterol, muscle pains. Most of the people in-taking this
drug complain about weakness, tiredness and heaviness in their whole body. Pain caused
can be normal or severe which solely depends on the body condition of an individual.
Q.1 (B) Use of nursing strategies to prevent risks
Consumption of medicines like atorvastatin has a huge side effect on body of an
individual. This drug is used by service users who are at threat of developing
hyperprolactinaemia. Patient is at risk of pain related to muscle or body. Strategies which can be
used by nurses to improve health-care conditions of patient comprise various interventions
various methods (Niemann and et.al., (2015). For example, to prevent side effects of the drug
nurses can implement a care plan which would be beneficial for users. This procedure may
consist of carers encouraging patients to involve in multiple physical activities like yoga, dance
and aerobics. It will help in reducing the side effects of medication.
Carers can advise service users to take medicine as directed and in appropriate quantity.
Excess intake of drugs can cause various disorders like nausea, cough, chest pain, etc. For
removing side effect health-care providers can also consult doctors who have prescribed it, whoi
can assist in limiting the use of such medications (Vaismoradi and et.al., 2014). Like for best
result, atorvastatin should be taken with hot water and must not be cracked, so Mr. Laurent have
to follow the applied conditions. Medicines such as Hydrocortisone given to patients also have
various side effects like insomnia, changing mood, acne, increased sweating and dry skin, etc.
Person consuming this medication is at risk of suffering from itching, fever and vomiting.
To manage threat, related to these drugs nurses looks after vital symptoms to see whether patient
is not allergic to it Karavasiliadou and Athanasakis (2014). Family and relatives also have an
idea about the use of these drugs. For preventing threat related to prescribed issues, the carers
should lay a major emphasis on patients to follow a healthy and nutritional diet. Limiting use of
alcohol or cigars can also help in preventing patient from these side effects.
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Q.2 Use of safety measures to prevent risk of medication errors
It is important for all health-care professionals, carers or nurses to be familiar with
various methods in order to reduce risk related to certain medicines. Strategies may consist of the
following:
Ensure the five rights of medication administration- Service providers must get assure
of organisational policies related to drug arrangement and compliance with guidelines. They
should get sure of all the facts that proper medicines are prescribed to patients on correct place
and time.
Have the specialist read it back- This procedure consists of a carer who goes through a
medical chart given by the experts to ensure that the prescribed drugs are consumed
appropriately. Organisation for improving its image can also refer to nurses to gain surety about
the prescribed medication.
Ensuring proper storage of medication and documents- Drugs and doses which needs
to be refrigerated should be kept in refrigerator by nurses in order to maintain their quality and
efficacy. Likewise, medicines that demands to be put at room temperature should be stored
wisely (Hayes and et.al., 2015). For example, glargine insulin which has been prescribed to Mr.
Laurent is required to be put in cool, dry place and out of the reach of children. This can lay a
positive impact on wellness of patient.
Following proper medication reconciliation procedures- Organisation must have
proper procedure in area for medical reconciliation when moving one service user from specific
hospital to anther that is transferring. Nurses have a responsibility to critically review and verify
each medicines prescribed for the appropriate patient on the basis of time, medication, dose and
route against moving order or drugs that are written on the transfer documents. Every possible
details includes information about patient's family, relatives, diseases and disorders which is
examined by nurses for authentic medication reconciliation. This will help organisation in
preventing medical errors.
Consider having a drug guide available at all the time- Medicines have several side
effects and to protest patients from that organisation, it should appoint a drug guide. This
particular person should be charge with duty to explain various benefits and threats related to
medications. Printed manual can also be made available to users about the advantages or risk
involved in consuming certain drugs (Ohashi and et.al., 2014). This guide should contain adverse
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reactions of medicines, drug interactions or medicine functionaries like drink with hot water,
consume before having food. It would help in creating awareness among users. Also, improve
mental and physical health condition of patients.
Documenting everything: It is the responsibility of nurse or hospital staff to provide
safe and secure environment to patient. Also, they have a duty to keep their information
confidential. Further, with proper medicine and safeguarding their data, health-care professionals
need to document every detail about them whether online or on manual basis for objective of
providing them.
Q.3 Benefits of regular consumption of intravenous (IV) erythromycin and ceftriaxone
Mr. Laurent who has been suffering from disorders like hypertension,
hyperprolactinaemia, diabetes, asthma is been prescribed to take intravenous (IV) therapy. This
procedure can provide patient with various benefits like it is the best method to induce nutrition
in human body. It helps in boosting energy of an individual in case he or she is suffering from
anxiety and depression. This therapy helps in consuming various vitamins which help in
improving physical health condition of patients. Service users can limit use of pills by in-taking
these processes 10 Strategies for Preventing Medication Errors (2017).
Laurent has been suggested to take erythromycin which helps in reducing bacterial
infection. It also supports in curing bronchitis, respiratory diseases, TIA etc. Consumption of this
tablet can make individual's immune system strong (Nanji and et.al., 2016). This will allow them
to fight against various bacterial infections. For example, Laurent can also use this drug in order
to recover from shortness of breath. They help in killing and stopping the growth of bacteria in
body.
Ceftriaxone is prescribed to those patients to treat conditions like lower respiratory tract
infection, urinary health problem, etc. It has been noted that Mr. Laurent outflow of urea is seen
at 9.2 mmol/L and normal range lies between 2.5 – 8.5 mmol/L. This medicine can help in
curing infection related to urinary bladder and kidney failure. Medical history of patient shows
that creatinine of individual lies between 150umol/L. This drug helps in curing these
deficiencies.
This is to summarise that study talks about disorders faced by Mr. Laurent. Medical chart
of patient shows that specialist has prescribed them with various medicines like atorvastatin,
ceftriaxone, salbutamol which are used for curing issues like diabetes, hyperprolactinaemia,
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hypertension, asthma etc. Various prevention measures like documenting everything, appointing
a drug guide are used to reduce medication errors.
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REFERENCES
Books and journals
Cudkowicz, M. E. & et.al., (2014). Safety and efficacy of ceftriaxone for amyotrophic lateral
sclerosis: a multi-stage, randomised, double-blind, placebo-controlled trial. The Lancet
Neurology.13(11). 1083-1091.
Das, S. C. & et.al., (2015). Ceftriaxone attenuates ethanol drinking and restores extracellular
glutamate concentration through normalization of GLT-1 in nucleus accumbens of male
alcohol-preferring rats. Neuropharmacology.97. 67-74.
Tsujita, K. & et.al., (2015). Impact of dual lipid-lowering strategy with ezetimibe and
atorvastatin on coronary plaque regression in patients with percutaneous coronary
intervention: the multicenter randomized controlled PRECISE-IVUS trial. Journal of
the American College of Cardiology.66(5). 495-507.
Komukai, K. & et.al.,(2014). Effect of atorvastatin therapy on fibrous cap thickness in coronary
atherosclerotic plaque as assessed by optical coherence tomography: the EASY-FIT
study. Journal of the American College of Cardiology.64(21).2207-2217.
Niemann, D. & et.al., (2015). A prospective three‐step intervention study to prevent medication
errors in drug handling in paediatric care. Journal of clinical nursing.24(1-2). 101-114.
Vaismoradi, M. & et.al., (2014). Nursing students' perspectives of the cause of medication
errors. Nurse Education Today. 34(3). 434-440.
Karavasiliadou, S. & Athanasakis, E. (2014). An inside look into the factors contributing to
medication errors in the clinical nursing practice. Health Science Journal.8(1).
Hayes, C. & et.al., (2015). Medication errors in hospitals: a literature review of disruptions to
nursing practice during medication administration. Journal of clinical nursing.24(21-
22). 3063-3076.
Ohashi, K., & et.al., (2014). Benefits and risks of using smart pumps to reduce medication error
rates: a systematic review. Drug safety. 37(12).1011-1020.
Nanji, K. C. & et.al., (2016). Evaluation of perioperative medication errors and adverse drug
events. Anesthesiology: The Journal of the American Society of
Anesthesiologists.124(1). 25-34.
Online
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10 Strategies for Preventing Medication Errors. (2017). [ONLINE] Available through:
<https://minoritynurse.com/10-strategies-for-preventing-medication-errors/>
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