Running head: NURSING CONSIDERATIONS IN A CASE STUDY

Nursing Care and Considerations in a Case Study

Maggie M. Fabry
California State University Stanislaus

NURSING CONSIDERATIONS IN A CASE STUDY

Nursing Care and Considerations in Pharmacology

Mr. Brown is a 65 year old patient who has a known history of Diabetes, hypertension,
and Alzheimers disease. This patient recently had a fall and a fracture of his left hip and is now
being admitted for surgery. Findings of significance made during his assessment include crackles
in the bases of his lungs, swelling in his lower extremities bilaterally, an elevated potassium level
of 5.5 and an elevated creatinine level of 1.5. In addition, Mr. Brown is alert and oriented times
two, has not had a bowel movement for three days and reports eight out of ten pain in his left hip.
His current vital signs are 37.6-88-24-165/96. During his stay, an assessment and evaluation of
his home medications, an investigation into the reason for his fall, considerations for a suitable
pain medication and interventions during post operative care will all prove to be important
nursing actions involved in the proper care of this patient.
The medications that Mr. Brown takes at home convey information about his health
problems. Firstly, Mr. Brown takes Spironolactone which is a potassium-sparing diuretic used
primarily for hypertension and edema. It acts through inhibiting the actions of aldosterone which
results in the increased secretion of sodium and the retention of potassium. Through this action,
Spironolactone creates osmotic pressure in the nephron, and passive reabsorption of water is
prevented. As a result of less water being present in the blood, blood volume and cardiac output
decline and blood pressure lowers. As a result of less water traveling into body tissues, edema is
reduced. Mr. Brown is receiving this medication because he has a known history of
hypertension and because he has pulmonary edema as suggested by the crackles present in the
bases of his lungs. Mr. Browns next home medication is Lisinopril which is a long-acting
angiotensin-converting-enzyme (ACE) inhibitor. Through inhibiting ACE, Lisinopril both
vasodilates and reduces blood volume. Lisinopril causes vasodilation through two actions. First,

NURSING CONSIDERATIONS IN A CASE STUDY

through inhibiting the angiotensin-converting enzyme, it prevents the conversion of angiotensin l

to angiotension ll which is a potent vasoconstrictor. Secondly, it inhibits kinase ll which
increases levels of bradykinin, a peptide that causes vasodilation. Blood volume is reduced
through the reduction of aldosterone which occurs secondary to the inhibition of angiotensin ll.
Vasodilation reduces peripheral resistance and lower blood volume reduces cardiac output,
which are the two primary determinants of blood pressure. Mr. Brown is taking Lisinopril at
home to lower his blood pressure because he has hypertension. Mr. Browns next home
medication is Metformin which is a part of the Biguanide family of oral agents used to treat type
2 diabetes. Type 2 diabetes is a disease in which the target tissues of insulin are resistant to its
effects, meaning that glucose does not get transported to these tissues, but rather accumulates in
the blood. Metformin improves tolerance to glucose and lowers blood glucose levels in the body
through three mechanisms of action. Firstly, Metformin inhibits the formation of glucose in the
liver. Secondly, it slightly lessens the absorption of glucose in the gut. Thirdly, it makes insulin
receptors more sensitive in fat and skeletal muscle and, as a result, increases the uptake of
glucose. The fact that the pt is taking a single oral hypotensive agent tells me that he has
recently been diagnosed with or has well controlled type 2 diabetes. Aricept is another of the
patients home medications. Aricept is a Cholinesterase inhibitor used in the treatment of
Alzheimers disease (AD). AD is a chronic, degenerative, progressive disease that consists of
memory loss, impaired thinking and neuropsychiatric symptoms. Although the cause is
unknown, what is known is that in pts with AD, levels of acetylcholine (ACh) are significantly
below normal. Aricept works to prevent the breakdown of ACh by acetylcholinesterase (AChE)
and, as a result, enhances the availability of ACh at cholinergic synapses. Through this action,
central cholinergic neurons that have not yet been destroyed by Alzheimers disease (AD) will

NURSING CONSIDERATIONS IN A CASE STUDY

have enhanced transmission. Aricept is the only cholinesterase inhibitor approved for AD
patients with severe symptoms. For this reason, it is reasonable to conclude that Mr. Brown has
AD and is displaying severe symptoms of the disease. Mr. Browns last home medication is
Prilosec which is a proton pump inhibitor (PPI) used to treat peptic ulcer disease (PUD). PUD
refers to a variety of disorders in the upper gastrointestinal tract that are distinguished by their
degree of erosion of the gut wall. Ulceration develops when there is an imbalance between
aggressive and defensive mucosal factors. A major aggressive factor is gastric acid. Once
activated in the parietal cells of the gut, Prilosec causes irreversible inhibition of H+,K+-ATPase
which is the enzyme that produces gastric acid (Lehne 2010). It is especially important that Mr.
Brown does not have an increased production of gastric acid in his stomach because he is taking
Spironolactone, which can cause gastric bleeding, ulceration and gastritis. All of these adverse
effects will have an increased risk of occurrence in the presence of excessive gastric acid
(Skidmore-Roth 2013).
Through investigating the patients assessment findings and his health history, judgments
can be made about the effectiveness of the medications he is taking at home. Due to the presence
of crackles in the base of his lungs and his severely elevated blood pressure, it is apparent that
Spironolactone is not effective in reducing blood pressure or edema for Mr. Brown. An
important side effect of Spironolactone is hyperglycemia. The patients dose of Metformin may
need to be increased accordingly (Skidmore-Roth 2013). Lisinopril is similarly ineffective. As
evidenced by his blood pressure of 165/96 during assessment, Lisinopril is failing to control the
patients blood pressure. Another area of concern is that both Spironolactone and Lisinopril
cause hyperkalemia (Lehne 2010). The patients current serum potassium level is elevated and
at 5.5, which confirms that these two medications should not be used together. One other

NURSING CONSIDERATIONS IN A CASE STUDY

important side effect of ACE inhibitors when looking at this patients results is the fact that they
can cause an elevated creatinine level (Pagana 2010). Metformin, on the other hand, is being
effective in lowering the patients blood glucose levels. The patients Hgb A1C is 7.0 which is
an acceptable value. It is important to mention that because Metformin does not stimulate the
release of insulin from the pancreas, it cannot cause hypoglycemia and is a good choice for
patients like Mr. Brown who skips meals (Lehne 2010). One interaction of note is the potential
for hypoglycemia when Lisinopril and a glucose lowering agent such as Metformin are used
together (Skidmore-Roth 2013). Aricept is also ineffective for this patient. This is evident by
the fact that the patient is alert and oriented times two. The patients recent fall may also be
indicative of increased confusion and disorientation associated with AD. In general,
Cholinesterase inhibitors only create modest and short lasting results for patients with AD
(Lehne 2010). Prilosec does appear to be effective in this patient. The patients complete blood
count was normal and did not display symptoms of gastrointestinal bleeding such as an elevated
red blood cell count, hemoglobin or hematocrit level (Pagana 2010). In addition, the patient is
not complaining of any stomach pain which can be an indication of erosion and ulceration
(Lehne 2010).
When looking at the patients history and assessment findings, reasonable deductions as
to the reason for Mr. Browns fall can be made. The first plausible reason for Mr. Browns fall is
the fact that he is taking Lisinopril which can cause orthostatic hypotension (Lehne 2010).
Orthostatic hypotension is a sudden decrease in blood pressure that results when rising to an
upright position. This sudden drop can result in lightheadedness and dizziness and in severe
cases, can cause fainting (Klingman 2013). A second reason for the fall could be the patients
high potassium level of 5.5 which can be the result of his use of both Spironolactone and

NURSING CONSIDERATIONS IN A CASE STUDY

Lisinopril. Characteristics of hyperkalemia that can contribute to falls are numbness or tingling
of the feet, weakness of the legs and confusion. A third and final reason for the fall could be the
patients AD. AD can cause memory loss and confusion, impaired judgment and disorientation
and feelings of being lost in surroundings that are familiar to the patient (Lehne 2010). All of
these changes caused by AD can increase the chances for falls.
A priority consideration for any patient with a fractured bone is pain control. In the case
of Mr. Brown, Morphine would be the most probable drug prescribed for his pain. Morphine is
an opioid analgesic used to relieve moderate to severe pain that is thought to act through binding
with opioid receptors in the CNS and altering both the perception of and emotional response to
pain (Skidmore-Roth 2013). Morphine reduces pain and anxiety, causes drowsiness and mental
clouding, and can induce a sense of well-being (Lehne 2010). Although Morphine has
potentially dangerous side effects such as seizures, bradycardia, cardiac arrest, shock,
thrombocytopenia, apnea, and respiratory depression, it has many beneficial effects for this
patient that outweigh the potential costs (Skidmore-Roth 2013). Another concern is that giving
Morphine can further delay a bowel movement for this patient who has not had one in three days
because it causes constipation. However, even if a moderate opioid agonist such a hydrocodone
was used, constipation would still be an adverse effect. A clear benefit of using Morphine with
this patient is that it can assist with sedation and anxiety reduction preoperatively. Morphines
side effect of respiratory depression can also serve as a benefit in this patient because his
respiratory rate is at an elevated 24 breaths per minute. Morphine can also cause hypotension
through its action of dulling the baroreceptor reflex. This effect can be positive for this patient
given his high blood pressure (Lehne 2010). Finally, it is a plus that Morphine can be given
intravenously (IV) because it results in rapid relief of pain for the patient. In contrast to oral

NURSING CONSIDERATIONS IN A CASE STUDY

analgesics which can take 30 minutes to display initial results, IV Morphine reaches its peak
effectiveness in 20 minutes (Skidmore-Roth 2013).
Orders for Promethazine and routine bowel care in this post-operative patient offer many
benefits, but also require numerous nursing considerations. Promethazine is a first-generation
H1 Antagonist and antiemetic that has been prescribed post-operatively to reduce anesthetic
related nausea. The obvious benefit of taking this medication is a relief of nausea which will
promote eating and mobility for this patient. Another benefit is that this drug causes sedation
and can therefore combat insomnia that is often present in patients with AD (Lehne 2010).
Important things to watch for when giving this drug are signs and symptoms of neuroleptic
malignant syndrome such as confusion, autonomic instability, muscle rigidity, and fever. It is
also important to monitor hydration level, mental status and for improvements in nausea
(Skidmore-Roth 2013). Routine bowel care will also benefit this patient through promoting
peristalsis and preventing constipation which can be both painful and potentially dangerous.
Routine bowel care includes interventions that increase peristalsis such as activity and mobility,
an increase in fiber intake, adequate hydration and the use of laxatives and stool softeners.
During the assessment of the abdomen, the nurse will be looking for signs of impaction such as a
hard distended stomach, hypoactive or absent bowel sounds and pain upon palpation. The nurse
will also be looking for adverse reactions of laxatives such as severe cramping, diarrhea and
nausea. Finally, the nurse must check for patient understanding after performing teaching on
proper fiber intake (eating three to five handfuls of fruits and veggies per day) and on proper
hydration (drinking two to three liters of water every day) (Lehne 2010).
Each patient a nurse cares for is unique and requires individualized care. In the case of
Mr. Brown, priority interventions include pain reduction, early ambulation and promotion of

NURSING CONSIDERATIONS IN A CASE STUDY

gastrointestinal motility. An important lesson to be learned through looking at Mr. Browns case
is the importance of initial assessments and of examining home medications for effectiveness
and interactions. Furthermore, Mr. Browns case demonstrated the importance of using critical
thinking and the nursing process in medication administration and in each and every other
nursing intervention.

NURSING CONSIDERATIONS IN A CASE STUDY

References
Klingman, L. (2013). Bowel Elimination. In P. A. Potter, A. G. Perry, P. A. Stockert, & A. M.
Hall (Eds.), Fundamentals of nursing (pp. 1087-1126). St. Louis, Missouri: Elsevier &
Mosby.
Lehne, R. A. (2010). Pharmacology for nursing care. St. Louis, Missouri: Saunders & Elsevier.
Pagana, K. D. & Pagana, T. J. (2010). Mosbys manual of diagnostic and laboratory tests. St.
Louis, Missouri: Mosby & Elsevier.
Skidmore-Roth, L. (Ed.). (2013). Mosbys 2013 nursing drug reference. St. Louis, Missouri:
Mosby & Elsevier.