Mrs A is a 71 year old widow with CCF and osteoarthritis who has recently been exhibiting quite unusual behaviour. Her daughter is concerned about her mother's ability to remain independent and wishes to pursue nursing home admission arrangements. She fears the development of a dementing illness. Over the last two to three months Mrs A has become confused, easily fatigued and very irritable. She has developed disturbing obsessive/compulsive behaviour constantly complaining that her lace curtains were dirty and required frequent washing. Detailed questioning revealed that she thought they were yellow-green and possibly mouldy. Her prescribed medications are:
* Frusemide 40 mg daily in the morning
* Digoxin 250 micrograms daily
* Paracetamol 500 mg, 1-2 tablets 4-hourly PRN
* Piroxicam 20 mg at night
* Mylanta suspension, 20 ml PRN
* Coloxyl 120 mg, 1-2 tablets at night
Critically discuss this case study in terms of the problematic nature of this patient's pharmacological management.
Your answer should include a discussion of the problems of polypharmacy as it is related to this case study and the assessment/management and educational strategies which could have been implemented to improve the outcome of Mrs A.
In analyzing the case study of Mrs A, a number of factors come into play. The patient has recently been exhibiting unusual symptoms including confusion, fatigue, irritability and apparent obsessive/compulsive behaviour. Her daughter fears the onset of a dementing illness. However, upon close examination of Mrs A's prescribed medications, very different conclusions can be drawn.
Overview of each Mrs A's medical conditions
The Online Medical Dictionary at www.mydr.com.au defines CCF as a condition where there is ineffective pumping of the heart leading to fluid retention and organ congestion. The site defines osteoarthritis as "Noninflammatory degenerative joint disease occurring chiefly in older persons." There are various drug treatments available for these conditions.
Polypharmacy and Mrs A's problematic pharmacological management
A close examination of Mrs A's drugs, serves to reveal the problematic nature of her pharmacological management and the results of polypharmacy.
Frusemide 40 mg daily in the morning
Loeb, S (2001:649) includes the following factors in his outline of frusemide.
Indications & dosage: Hypertension - adults 40 mg P.O. b.i.d. Adjust dose according to response.
Adverse reactions: Hypokalemia (low potassium), fluid and electrolyte imbalances.
Relevant interactions: Care should be exercised in patients receiving potassium depleting agents.
Nursing considerations: Monitor serum potassium level. Watch for signs of hypokalemia (for example fatigue, muscle weakness and cramps). Give P.O. and I.M. preparations in a.m. to prevent nocturnia.
Applications to case study
It is likely that frusemide is being given to Mrs A as diuretic therapy to treat fluid retention typically associated with Congestive Cardiac Failure. Mrs A's dose of 40 mg daily in the morning is a standard initial dose however it should be adjusted according to response. Morning dose is correctly implemented to alleviate sleeplessness and reduce gastric disturbance.
Frusemide could be increasing Mrs A's sensitivity to digoxin. As such, an alternate drug such as Zantac may be advisable. Moreover, a high potassium diet may help reduce potassium loss and the risk of hypokalaemia whilst eliminating the need for potassium supplements. Mrs A needs to be monitored for symptoms of hypokalaemia and her serum potassium levels checked.
Digoxin 250 micrograms daily
McKenry, L & Salerno, E (1989:454-458) includes the following factors in their outline of digoxin.
Indications & dosage: In elderly patients, an initial dose of 500 to 750 micrograms may be given as a single dose. Maintenance dose for adults over 65 years is 125 micrograms P.O. daily and...
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