NURS 6521: Week 9 Assignment – Case Study Evaluations and Prescriptions

### Scenario 1: Jamie, 38-year-old Homeless Bipolar Patient with Acute Psychotic Episode

#### Problem Explanation:
Jamie is experiencing an acute psychotic episode. His current medications are lithium, a mood stabilizer, and amitriptyline, a tricyclic antidepressant. The combination of lithium and amitriptyline can increase the risk of serotonin syndrome and other side effects.

#### Treatment Plan:
1. **Discontinue Amitriptyline**: Amitriptyline can exacerbate Jamie’s psychosis and interact adversely with lithium.
2. **Continue Lithium**: Maintain his current lithium therapy as it is crucial for managing his bipolar disorder.

3. **Start Antipsychotic Medication**:
– **Medication**: Risperidone
– **Dose**: 1 mg
– **Route**: Oral
– **Frequency**: Twice daily (BID)
– **Special Instructions**: Increase gradually based on response and tolerance, max 6 mg/day.
– **# Dispensed (days supply)**: 30-day supply
– **Refills**: 1

4. **Monitor**:
– Lithium levels: Regular monitoring to maintain therapeutic range (0.6-1.2 mEq/L)
– Renal function: Monitor creatinine and thyroid function tests.
– Side effects: Watch for symptoms of extrapyramidal side effects and metabolic syndrome.

#### Prescription:
– **Risperidone 1 mg po BID**
– Special instructions: Increase gradually based on response and tolerance, max 6 mg/day.
– Dispense: 60 tablets (30-day supply)
– Refills: 1

**Sources:**
– American Psychiatric Association. (2013). Practice guideline for the treatment of patients with bipolar disorder.
– Hirschfeld, R. M. A., et al. (2005). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). American Psychiatric Association.
– Medscape: Antipsychotics and their use in acute psychosis.

### Scenario 2: 68-year-old Woman with Rheumatoid Arthritis

#### Problem Explanation:
The patient is experiencing worsening rheumatoid arthritis pain despite being on nabumetone. She has a history of Crohn’s disease and diabetes, which complicates the management.

#### Treatment Plan:
1. **Continue Nabumetone**: Maintain current dose if tolerable and not causing significant gastrointestinal issues.
2. **Add Disease-Modifying Antirheumatic Drug (DMARD)**:
– **Medication**: Methotrexate
– **Dose**: 10 mg
– **Route**: Oral
– **Frequency**: Once weekly
– **Special Instructions**: Folic acid supplementation recommended to mitigate side effects.
– **# Dispensed (days supply)**: 4-week supply
– **Refills**: 0 (follow-up required for monitoring)

3. **Monitor**:
– Liver function tests: Baseline and every 4-8 weeks.
– Complete blood count (CBC): Baseline and every 4-8 weeks.
– Renal function tests: Regular monitoring.

#### Prescription:
– **Methotrexate 10 mg po once weekly**
– Special instructions: Folic acid 1 mg po daily.
– Dispense: 4 tablets (4-week supply)
– Refills: 0

**Sources:**
– American College of Rheumatology. (2015). Guidelines for the treatment of rheumatoid arthritis.
– Singh, J. A., et al. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 68(1), 1-25.
– Medscape: Methotrexate for rheumatoid arthritis.

### Scenario 3: Sheila, 26-year-old with History of Head Injury and Seizures

#### Problem Explanation:
Sheila’s symptoms of “funny” eye movements, uncoordinated feeling, blurred vision, and lethargy may be related to her Dilantin (phenytoin) therapy. Her Dilantin level is subtherapeutic, and her low albumin level affects the drug’s binding and efficacy.

#### Treatment Plan:
1. **Adjust Dilantin Dose**: Increase to achieve therapeutic levels considering low albumin.
2. **Continue Current Medications**: Monitor for side effects.

3. **Corrected Phenytoin Level Calculation**:
– Formula: Corrected level = Measured level / [(0.2 * Albumin) + 0.1]
– Corrected level: 11 / [(0.2 * 2) + 0.1] = 11 / 0.5 = 22 (still subtherapeutic)

4. **Increase Dilantin Dose**:
– **Medication**: Phenytoin
– **Dose**: 400 mg
– **Route**: Oral
– **Frequency**: Once daily (at bedtime)
– **# Dispensed (days supply)**: 30-day supply
– **Refills**: 1

5. **Monitor**:
– Dilantin levels: Regular monitoring to adjust dosage.
– Liver function and CBC: Regular intervals.

#### Prescription:
– **Phenytoin 400 mg po once daily**
– Dispense: 30 tablets (30-day supply)
– Refills: 1

**Sources:**
– American Epilepsy Society. (2018). Guidelines for the treatment of convulsive status epilepticus in adults and children.
– Kanner, A. M., et al. (2018). Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy. Neurology, 91(2), 82-90.
– Medscape: Phenytoin (Dilantin) dosage and administration.

### Scenario 4: Xavi, 44-year-old with Low Back Pain

#### Problem Explanation:
Xavi is experiencing severe low back pain following a motor vehicle accident. He was prescribed Lortab (hydrocodone/acetaminophen) but requires additional pain management.

#### Treatment Plan:
1. **Discontinue Lortab**: Given its limited efficacy.
2. **Start a Stronger Analgesic**:
– **Medication**: Oxycodone/Acetaminophen
– **Dose**: 5/325 mg
– **Route**: Oral
– **Frequency**: Every 6 hours as needed for pain
– **# Dispensed (days supply)**: 40 tablets (10-day supply)
– **Refills**: 0

3. **Additional Medications**:
– **NSAID**: Ibuprofen 400 mg po q6h prn for inflammation and pain.

4. **Monitor**:
– Pain levels: Regular assessments.
– Signs of opioid dependence or adverse effects.

#### Prescription:
– **Oxycodone/Acetaminophen 5/325 mg po q6h prn pain**
– Dispense: 40 tablets (10-day supply)
– Refills: 0
– **Ibuprofen 400 mg po q6h prn pain**
– Dispense: 20 tablets (5-day supply)
– Refills: 0

**Sources:**
– American Pain Society. (2016). Clinical guidelines on the use of chronic opioid therapy in chronic non-cancer pain.
– Chou, R., et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. Journal of Pain, 10(2), 113-130.
– Medscape: Oxycodone/Acetaminophen usage and dosing.

**APA Format Citations:**
– American Psychiatric Association. (2013). Practice guideline for the treatment of patients with bipolar disorder.
– Hirschfeld, R. M. A., et al. (2005). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). American Psychiatric Association.
– Singh, J. A., et al. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 68(1), 1-25.
– Kanner, A. M., et al. (2018). Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy. Neurology, 91(2), 82-90.
– Chou, R., et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. Journal of Pain, 10(2), 113-130.

 

## NURS 6521: Week 9 Assignment

### Scenario 1: Jamie, 38-year-old Homeless Bipolar Patient with Acute Psychotic Episode

**Problem Explanation:**
Jamie is experiencing an acute psychotic episode while on lithium for bipolar disorder and recently started on amitriptyline 25 mg po TID. Amitriptyline can worsen psychosis and its combination with lithium can increase the risk of serotonin syndrome.

**Treatment Plan:**
1. **Discontinue Amitriptyline**: Due to potential exacerbation of psychosis and interaction with lithium.
2. **Continue Lithium**: Maintain for mood stabilization.
3. **Add Antipsychotic Medication**:
– **Medication**: Risperidone
– **Dose**: 1 mg
– **Route**: Oral
– **Frequency**: Twice daily (BID)
– **Special Instructions**: Increase gradually based on response and tolerance, max 6 mg/day.
– **# Dispensed (days supply)**: 60 tablets (30-day supply)
– **Refills**: 1

**Prescription:**
– **Risperidone 1 mg po BID**
– Special instructions: Increase gradually based on response and tolerance, max 6 mg/day.
– Dispense: 60 tablets (30-day supply)
– Refills: 1

**Monitoring:**
– Lithium levels: Regular monitoring to maintain therapeutic range (0.6-1.2 mEq/L).
– Renal function: Monitor creatinine and thyroid function tests.
– Side effects: Watch for extrapyramidal side effects and metabolic syndrome.

**References:**
– American Psychiatric Association. (2013). Practice guideline for the treatment of patients with bipolar disorder.
– Hirschfeld, R. M. A., et al. (2005). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). American Psychiatric Association.
– Medscape. Risperidone. Retrieved from https://www.medscape.com

### Scenario 2: 68-year-old Woman with Rheumatoid Arthritis

**Problem Explanation:**
The patient is experiencing worsening rheumatoid arthritis pain despite nabumetone 1000 mg po qd. She has a history of Crohn’s disease, diabetes, and incontinence, which complicates her management.

**Treatment Plan:**
1. **Continue Nabumetone**: If tolerable and not causing significant gastrointestinal issues.
2. **Add DMARD**:
– **Medication**: Methotrexate
– **Dose**: 10 mg
– **Route**: Oral
– **Frequency**: Once weekly
– **Special Instructions**: Folic acid 1 mg daily to mitigate side effects.
– **# Dispensed (days supply)**: 4 tablets (4-week supply)
– **Refills**: 0 (follow-up required for monitoring)

**Prescription:**
– **Methotrexate 10 mg po once weekly**
– Special instructions: Folic acid 1 mg po daily.
– Dispense: 4 tablets (4-week supply)
– Refills: 0

**Monitoring:**
– Liver function tests: Baseline and every 4-8 weeks.
– CBC: Baseline and every 4-8 weeks.
– Renal function tests: Regular monitoring.

**References:**
– American College of Rheumatology. (2015). Guidelines for the treatment of rheumatoid arthritis.
– Singh, J. A., et al. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 68(1), 1-25.
– Medscape. Methotrexate. Retrieved from https://www.medscape.com

### Scenario 3: Sheila, 26-year-old with History of Head Injury and Seizures

**Problem Explanation:**
Sheila’s symptoms of eye movements, uncoordinated feeling, blurred vision, and lethargy may be due to subtherapeutic Dilantin (phenytoin) levels. Her low albumin affects the drug’s binding and efficacy.

**Treatment Plan:**
1. **Adjust Dilantin Dose**: Increase to achieve therapeutic levels considering low albumin.
2. **Continue Current Medications**: Monitor for side effects.

**Corrected Phenytoin Level Calculation:**
– Formula: Corrected level = Measured level / [(0.2 * Albumin) + 0.1]
– Corrected level: 11 / [(0.2 * 2) + 0.1] = 11 / 0.5 = 22 (still subtherapeutic)

**Increase Dilantin Dose:**
– **Medication**: Phenytoin
– **Dose**: 400 mg
– **Route**: Oral
– **Frequency**: Once daily (at bedtime)
– **# Dispensed (days supply)**: 30 tablets (30-day supply)
– **Refills**: 1

**Prescription:**
– **Phenytoin 400 mg po once daily**
– Dispense: 30 tablets (30-day supply)
– Refills: 1

**Monitoring:**
– Dilantin levels: Regular monitoring to adjust dosage.
– Liver function and CBC: Regular intervals.

**References:**
– American Epilepsy Society. (2018). Guidelines for the treatment of convulsive status epilepticus in adults and children.
– Kanner, A. M., et al. (2018). Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs II: Treatment-resistant epilepsy. Neurology, 91(2), 82-90.
– Medscape. Phenytoin (Dilantin) dosage and administration. Retrieved from https://www.medscape.com

### Scenario 4: Xavi, 44-year-old with Low Back Pain

**Problem Explanation:**
Xavi is experiencing severe low back pain following a motor vehicle accident. He was prescribed Lortab (hydrocodone/acetaminophen) but requires additional pain management.

**Treatment Plan:**
1. **Discontinue Lortab**: Given its limited efficacy.
2. **Start a Stronger Analgesic**:
– **Medication**: Oxycodone/Acetaminophen
– **Dose**: 5/325 mg
– **Route**: Oral
– **Frequency**: Every 6 hours as needed for pain
– **# Dispensed (days supply)**: 40 tablets (10-day supply)
– **Refills**: 0

3. **Additional Medications**:
– **NSAID**: Ibuprofen 400 mg po q6h prn for inflammation and pain.

**Monitoring:**
– Pain levels: Regular assessments.
– Signs of opioid dependence or adverse effects.

**Prescription:**
– **Oxycodone/Acetaminophen 5/325 mg po q6h prn pain**
– Dispense: 40 tablets (10-day supply)
– Refills: 0
– **Ibuprofen 400 mg po q6h prn pain**
– Dispense: 20 tablets (5-day supply)
– Refills: 0

**References:**
– American Pain Society. (2016). Clinical guidelines on the use of chronic opioid therapy in chronic non-cancer pain.
– Chou, R., et al. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. Journal of Pain, 10(2), 113-130.
– Medscape. Oxycodone/Acetaminophen usage and dosing. Retrieved from https://www.medscape.com

 

 

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