NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics Post

After reviewing the learning resources and reflecting on past clinical experiences, it is imperative that the healthcare practitioner has a full understanding of the patient’s clinical status and how medications will either help or hinder a patient’s condition. This includes but is not limited to the mechanism in which a medication is absorbed and metabolized and how a patient’s comorbidities may impact the effect of a prescribed medication. A healthcare practitioner must have an understanding of both pathophysiology and pharmacology in order to prescribe medications effectively NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics. There are many aspects to consider when prescribing medication while keeping the patient’s well-being the primary goal. Pharmacodynamics and pharmacokinetics specific to an individual patient, in conjunction with ethics, and legality must all be considered prior to prescribing medication. The risks of the medication versus the benefits must also be weighed prior to prescribing medications.

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Past clinical experience

As an RN in the subacute care and long term care setting, there are many instances in which the patient was impacted by a medication prescribed. NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics. Specifically, I would like to describe a patient case involving psychotherapeutic medications. Working in the type of setting that consists mainly of the elderly population, the use of psychiatric medication must be closely studied. Many of these patients have some level of dementia, and others may simply have an altered mental status due to the fact that they have not adapted to their recent change in environment. As a nurse, unfortunately I have witnessed practitioners “jump” to place these patients on high doses of psychotherapeutic medication, including anti-psychotics and anxiolytics. A specific patient that I recall, was admitted to our facility with the diagnosis of UTI that the patient was previously treated for in the acute care setting. The patient also had preexisting conditions that included type 2 diabetes as well as cardiovascular disease. When reconciling the patient’s medications with her family, I noted that the practitioner had added both aripiprazole (Abilify) and lorazepam (Ativan) to her medication regimen. After reading more into the hospital record, it was evident that the patient had significant confusion while being treated for the infection which is very common in this patient population. While in the hospital, had behaviors such as yelling out, climbing out of bed, and general disorientation that most likely prompted the prescriber to order these medications with the goal of preserving the patient’s safety and also enabling the staff to manage her care effectively NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics. However, the patient’s baseline mental status prior to hospitalization was alert and oriented to person, place, time and, situation. After admission to my facility for rehabilitation, the practitioner made the decision to keep the patient on the psychiatric medication. The staff noticed that the patient was having many disturbances in her cognition including auditory, visual, and tactile hallucinations. She was also combative, and the Ativan would lower her inhibitions making her at a higher risk for falling or sustaining other injuries. Additionally, the patient was lethargic for most of the day and therefore unable to participate in therapy. After several attempts to have the practitioner evaluate the patient’s medication regimen to no avail, the patient was consulted by psychiatry. The Abilify was discontinued, and the Ativan was tapered to a lower PRN dosage. The patient’s hallucinations and lethargy had greatly decreased. She was able to return back to her baseline status after being rehabilitated. In this case, it seemed as though both the Abilify and Ativan were not optimal in treating this patient. NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics It is important that the practitioner evaluates adverse effects of medication in the elderly (Journal of the American Geriatrics Society, 2019). Although, some psychotherapeutic medication may have been necessary, especially when the patient had an acute UTI, in this case I feel that the patient should have been closely evaluated, as well as evaluating her medication regimen. Recent literature states patients who are in long term care facilities are at a higher risk for being prescribed these medications, without sufficient rationale (Markota, Rummans, Bostwick, & Lapid, 2016). NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics.

Plan of care

This type of scenario that I previously described happens often in the subacute and long term care setting. It is not uncommon to see practitioners prescribe exorbitant amounts of psychiatric medications, seemingly without a full assessment of the patient’s clinical status, comorbidities, and other medications. With that being said, recently Medicare has become more stringent when prescribing psychoactive medications, specifically anxiolytics and hypnotics. This protocol includes prescribing this type of medication at 14 day intervals, in which the practitioner after the 14 days must evaluate the patient fully before ordering the continuation of this medication. If the medication is to continue, there needs to be significant documentation that addresses the rationale for the usage of the medication. This protocol has significantly reduced the amount of psychotherapeutic medications being prescribed to the elderly. The practitioners are now looking much closer at the pharmacodynamics, pathophysiology, pharmacokinetics, and patient outcomes which has enabled the caregivers to provide this population with a higher standard of care. As part of my personalized plan of care for this patient, it would have been a priority to fully assess the patient and their medical history, reviewing recent lab results, blood sugars, and also reviewing any pertinent diagnostic tests such as an ECG. Cardiac arrhythmias and sedation are both potential adverse effects which may occur in the elderly when given Abilify, especially if they have a cardiac history (Kirino, 2015). Given the scenario, I would also legally follow the 14 day protocol and assess the need to keep the patient on Ativan, as this medication may cause the patient to be prone to falls and other injuries. As a practitioner, I would have ordered psychiatry and psychotherapy to see the patient as a priority with the goal of maintaining her safety. NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics

*I have attached a copy of my references in APA formatting, as I know sometimes the spacing is off when posting in the forums.References1.docx

References

American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate

Medication Use in Older Adults. (2019). Journal of the American Geriatrics

Society, 67(4), 674–694. doi: 10.1111/jgs.15767

Kirino, E. (2015). Use of aripiprazole for delirium in the elderly: a short review.

Psychogeriatrics, 15(1), 75–84. https://doi-

org.ezp.waldenulibrary.org/10.1111/psyg.12088

Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine use in

older dults: dangers, management, and alternative therapies. Mayo Clinic Proceedings,

91(11), 1632–1639. https://doi

org.ezp.waldenulibrary.org/10.1016/j.mayocp.2016.07.024 NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics

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NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics response

Reading your post recalls the importance of good clinical and pharmacological knowledge in healthcare practice, especially when caring for the elderly. These group of patients are more likely to have mental alterations from disease conditions like urinary tract infections (UTI). For this patient, the ideal plan of care would be a urinary culture to isolate the causative organism for sensitivity and appropriate antibiotics therapy. Urinary tract infection is known as a common cause of sudden episode of delirium and confusion in elderly patients, mostly among women and related to poor perineal/genital care and incontinence. But about four times as many women get UTIs as men and higher with diagnosis of diabetes mellitus (Medline.gov, 2020). The initiation of a broad-spectrum antibiotics like intravenous Ceftriaxone (Rocephin), while awaiting culture results is necessary too. NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics

I agree on your plan to involve psychiatry and psychotherapy on her care, as a safety measure.  Clinicians need information on the relative risks and dangers of antipsychotic medications on the elderly population. In the United States, all antipsychotics has an FDA “black-box” warning of the increased risk of death in older adults with dementia (Kales, Mulsant & Sajatovic, 2017). The risk of demise is  also increased when prescribing antipsychotics to older adults with other health conditions, such as Parkinson’s disease, with high risk of  falls/injuries, fractures, extreme sedation, metabolic abnormalities, and other extrapyramidal effects (Kales, Mulsant & Sajatovic, 2017).

References

Kales, H.C., Mulsant, B.H & Sajatovic, M. (2017). Prescribing antipsychotics in geriatric patients: Focus on dementia. Https://www.mdedge.com/psychiatry/article/152966/geriatrics/prescribing-antipsychotics-geriatric-patients-focus-dementia

Medineplus.gov. (2020). Urinary tract infections. Https://medlineplus.gov/urinarytractinfections.html  NURS 6521 Week 1 Discussion: Pharmacokinetics and Pharmacodynamics