Choice #3 Lester
According to Woo and Robinson (2020), warfarin (Coumadin) is an oral anticoagulant, which inhibits the hepatic synthesis of several clotting factors. It is rapidly and completely absorbed through oral intake, and the anticoagulant effect is dependent on the body breaking down the clotting factors. Warfarin is highly bound to plasma protein. Warfarin starts to take effect in about 3 to 5 days and can last in the body for about 2 to 5 days. If the patient has hepatic dysfunction, then the bodys response to warfarin may be hindered. Additionally, hypermetabolic states that are caused by fever or hyperthyroidism can increase warfarins effects and further breakdown vitamin K-dependent coagulating factors. Patients with these specific problems should take caution. For older adults, the patient should be cautious when taking warfarin because there is a decreased risk for thromboembolism and an increased risk for bleeding, especially for patients who have dementia or severe cognitive impairment. Additionally, older adults with a history of three falls within the past year, uncontrolled hypertension, or those who are non-adherent or unreliable in taking medications should be watched carefully when taking warfarin. There is also an increased risk for stroke in patients who are newly diagnosed with atrial fibrillation and have started on warfarin.
As the patients health care provider and nurse practitioner, I would provide Lester with education regarding the information on warfarin. Lester is a newly diagnosed patient with atrial fibrillation. He is 67 years old and has a lot of concerns regarding the diagnosis and the newly added medication. I would let him know how warfarin works and why it is chosen for atrial fibrillation. I would give him the pertinent information needed regarding his care. Because he states that he is forgetful about taking medications, I would have him try a few things that could help him remember to take his medication. For instance, if he uses a smartphone, I recommend using an alarm and set it as a daily reminder to take his medications. I would also like to have a family member be involved to help him remember to take his medication. Routines are a good way to help remember to take prescribed medications. The patient should also make a list of medications that he is taking as well as diagnoses pertinent to those medications. It should also be displayed in an area where he frequently walks in such as on the refrigerator. To add to the pertinent information from the first paragraph regarding warfarin, I would also talk about what could happen if there is too much warfarin in the body.
When the patient takes too much warfarin one way to solve this problem is to have the patient withhold one or more doses to help decrease the levels of warfarin in the body. However, if additional medications need to be added to treat warfarin toxicity, then I would prescribe vitamin k, which is the antidote for warfarin overdose or minor bleeding. Also, cyanotic toes in men have been observed when the INR levels are within the therapeutic range. It is best to let the patient know to look out for these symptoms. This can be due to an inhibition in proteins S and C in patients whose clotting factors are absent and patients with heparin-induced thrombocytopenia. Allergic reactions to warfarin are rare. But if it does happen, Lester should watch out for symmetrical, maculopapular, erythematous lesions that can occur on the face, neck, and torso (Woo & Robinson, 2020). Another concern to bring up with Lester is that there could be a drug-to-drug interaction when taking warfarin. For instance, if Lester was prescribed cephalosporins or penicillins, there is an increased risk of bleeding so he should further investigate this if he needs antibiotics. Lester should not take vitamin K because it decreases the effectiveness of warfarin. Additionally, inhibitors of CYP1A2, CYP2C9, or CYP3A4 isoenzymes increase the effectiveness of warfarin so it should be avoided. Inducers of CYP1A2, CYP2C9, or CYP3A4 induce and inhibit the effectiveness of warfarin. Other drugs that Lester should avoid are as follows: anticoagulants, antiplatelets, NSAIDs, SSRIs, antifungals, herbal therapies, and foods (St. Johns wort, ginseng, echinacea, ginkgo, goldenseal, grapefruit juice, and coenzyme Q10). It is important to follow up with blood tests when taking warfarin because there is a therapeutic range to have the medication effective. The patient may either need to increase or decrease the dose depending on the lab value to make sure that the medication helps his new diagnosis of atrial fibrillation, which is a common cardiac arrhythmia. About 1 in 4 persons experience atrial fibrillation in their lifetime (Woo & Robinson, 2020). The irregularity and turbulence associated with atrial fibrillation place the patient at risk. That would be the reason for me prescribing warfarin for the patient. I can ensure that my patient education and information regarding warfarin and atrial fibrillation is up to date and accurate by using evidence-based research. According to Lip et al. (2017), effective stroke prevention in patients with atrial fibrillation is by prescribing and having the patients use oral anticoagulants, including warfarin. Warfarin significantly reduced the risk of stroke by 64 percent. Ideal management requires optimization of warfarin therapy within a therapeutic range of INR from 2 to 3.
Essentially, being forgetful, having a new diagnosis, and having many questions regarding a visit with the doctor or nurse practitioner can be overwhelming for the patient. Lester has the right to ask questions and obtain all needed information before leaving the clinic. I would make sure that Lester repeats all educational material to see what he absorbed. Additionally, I would have the patient follow up in the clinic to make sure that he is not being forgetful and to see if he has established a routine to help him remember to take his medications. I would also make sure to address additional questions he may have.
Jana, a 36-year-old single mother of three children, has a 15-year history of asthma. For the past month, she has been using albuterol every day. Previously, she had been using the inhaler every 3 to 4 months. She is in the office for a refill. What further information is needed to treat this patient and why? What clinical guidelines should you refer to for her medication management and why?
I would try to find out other information like if Jana is taking Digoxin, other sympathomimetics, MAOIs, TCAs, Beta blockers (including any ophthalmic agents), cocaine use, or thyroid hormones. If she does take these other drugs along with Albuterol, there can be potential side effects and interactions with the medications. Such side effects could include cardiac effects, arrhythmias, or CNS effects (Woo & Robinson, 2020). I would educate her about that. Id also let her know that Albuterol can increase her heart rate. Salmeterol could also be an alternative to the Albuterol because it is a longer acting broncho protection. The half-life for Salmeterol is 10-12 hours. Other alternatives can include other routes of Albuterol. Albuterol comes in inhaled form, oral form, and in syrup form. However, the syrup form is not used often since the inhaled form is more effective and has fewer adverse effects. Ipratropium which is an anticholinergic can also be used along with Albuterol to treat asthma exacerbation commonly used in the emergency department. A guideline that could be followed would be, The Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma and the Global Initiative for Asthma. The dose of Albuterol to prevent exercised induced bronchospasm is two puffs 15 minutes before exercise, which should prevent exercised induced bronchospasm for 2 to 3 hours. The dose of salmeterol is two puffs 30 to 60 minutes before exercise. Salmeterol should prevent exercised induced bronchospasm for 10 to 12 hours. Salmeterol and other long-acting beta adrenergic have a shortened duration of action if used on a daily basis and may mask persistent asthma symptoms (Woo & Robinson, 2020). This would be something I would make Jana aware of, if she decides to try using Salmeterol. Albuterol in regards to cost is the least expensive of the short acting bronchodilators. So, this something I would take into account for Jana as well. Ipratropium could be used in combination with Albuterol. Ipratropium adult dosing is two to three inhalations four times a day. This is not to be used for exercise-induced asthma. Adult dosing for ipratropium nebulizer solution is 250 mcg four times a day. Ipratropium can be mixed with Albuterol if the combination is used within 1 hour of the asthma exacerbation. Dosing for acute exacerbation of asthma can be referred to in the National Institutes of Health (NIH) guidelines. The second-line, quick-relief medication in the treatment of asthma is ipratropium- albuterol combination (Combivent). The adult dosing for Combivent is two to three inhalations at four times a day. When I decide to prescribe both ipratropium and albuterol together, the appropriate choice would be to prescribe Jana Combivent which is the combination product of ipratropium- albuterol. So, when prescribing this medication to Jana I would take into account what these drugs will cost her. The cost of Combivent will be about $420 or $250 for DuoNeb (ipratropium and albuterol nebulizer solution) every 30 vials, which would be a significant cost savings for her over prescribing the two products individually. The generic combination product is even less expensive at $32.47 for ipratropium/albuterol nebulizer solution (Woo & Robinson, 2020). This is something I would need to familiarize myself with when it comes to making prescribing decisions regarding. It could cost Jana less to prescribe the combined medication for COPD, or depending on her prescription drug coverage, it may cost her less to just prescribe each medication separately. The final thing I would do is discuss lifestyle improvements with Jana like: Self-monitor her respiratory status with a peak flowmeter to determine the effectiveness of her medication regimen, she should avoid or quit smoking, she should avoid environmental triggers for asthma at home, work, or anywhere she goes, and she should avoid any unnecessary exposure to viral respiratory infections (Woo & Robinson, 2020). According to Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, as the provider I would refer to this guideline for her follow up asthma visit, the guidelines/steps to follow are: Assess and monitor asthma control, review medication technique and adherence; assess side effects; review environmental control, maintain, step up, or step down medication, review asthma action plan, revise, as needed, and schedule next follow up appointment (Asthma Care Quick Reference 2020). In addition, it would also be beneficial to Jana to discuss an action plan for asthma exacerbation. Per Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, I would discuss with her and create a written action plan. For at home care of asthma exacerbation the action plan would include recognizing the early signs and symptoms, and peak expiratory flow measures that indicate worsening asthma, alter the medications and remove or withdraw from environmental factors any causative factors to the asthma exacerbation, observe the response, seek medical care if there is serious decline or lack of reaction to the action plan, and give precise guidelines on who and when to call. Then I would discuss with Jana the action plan for an emergency exacerbation. The action plan for an emergency exacerbation would include evaluating the severity by lung function methods, physical examinations, and signs and symptoms, discuss methods to relieve hypoxemia and airflow obstruction; decrease the airway irritation, use supplemental oxygen to correct hypoxemia, treat it with repetitive or continuous short acting beta2 adrenergic, with the addition of inhaled ipratropium bromide in severe exacerbations, furnish oral systemic corticosteroids in moderate or severe exacerbations or for patients who fail to respond straightway and entirely to short acting beta2 adrenergic, think of adjunctive managements, for example utilizing intravenous magnesium sulfate or heliox, in severe aggravations that are unresponsive to treatment, supervise the response with repeat assessment of lung function measures, physical examination, and signs and symptoms, in the emergency department, monitor the pulse oximetry, make sure to discharge the patient with medication and with patient education, medications would comprise of short acting beta2 adrenergic and oral systemic corticosteroids; consider starting inhaled corticosteroids, refer to follow-up care, construct an asthma discharge plan, review the patients inhaler skill and if possible, measure the environmental control (Asthma Care Quick Reference 2020).
