Pharmacology Case Study

This is an application of the knowledge from Unit 7 to a case study involving a 60-year-old man who presents to my clinic with complaints of a productive cough and shortness of breath for 2 weeks. The patient has smoked at least one pack of cigarettes a day for the last 45 years. He denies fever or chest pain except with his cough. This paper will include a discussion of the assessment data gathered upon which his treatment and education plans are based. It will include practice guidelines from the literature as evidence for the treatment and education plans.

Finally, I will conclude with a summary regarding this case study. Assessment Date Here is a 60-year-old man presenting with complaints of a productive cough and shortness of breath for 2 weeks. He has smoked at lease one pack of cigarettes a day for the last CASE STUDY: MN 553 UNIT 7 2 45 years. He denies fever or chest pain except with coughing. He has been using his albuterol inhaler at least 6 times a day. His past medical history includes hypertension and chronic obstructive pulmonary disease (COPD). His lung sounds are coarse to auscultation throughout, and there are audible wheezes.

The patient coughs with deep inspiration, and there is mild retracting noted. His blood pressure is 126/80 mmHg, his respiratory rate is 20 per minute, and his heart rate is 80 beats per minute. His oxygen saturation is 91% on room air. Currently, his medications include albuterol HFA and atenolol XL 50mg daily at bedtime. Findings In reviewing this client’s medications, I have some concerns. First of all, he is taking the maximum recommended dosage of albuterol HFA. Albuterol HFA is a short-acting beta agonist that is used to relieve bronchoconstriction by relaxing smooth muscle in the respiratory tract.

(Gutierrez, 2008). The usual dosage of albuterol for adults is two puffs every 4 to 6 hours (DailyMed, 2008). Some patients taking albuterol HFA who exceed the recommended dose have died of sudden cardiac arrest (DailyMed, 2008). I will need to prescribe something else to treat his shortness of breath and provide a more long-term effect. Also, he is taking atenolol XL, a selective beta-adrenergic blocker, for his hypertension. Gutierrez (2008) says that beta-adrenergic blockers, selective or non-selective, are contraindicated in patients with COPD, because of the risk of bronchospasm.

I will need to change his atenolol XL to a different type of anti-hypertensive medication to prevent this adverse effect. Additional Information In reviewing this case, I need some additional information. I would like to get his temperature to see if he has a fever. His weight and any recent weight loss or anorexia will help me determine the severity of his COPD. A chest x-ray will help me identify the presence of any CASE STUDY: MN 553 UNIT 7 3 pneumonia. I would like to obtain a CBC with differential, a BUN and creatinine, LFTs, glucose, potassium, and a sputum specimen, if possible. Next, I would inquire about his allergies.

Knowledge of his allergies will help me prescribe the correct medications. I would like to obtain spirometric measurements to assess his forced vital capacity (FVC) and his forced expiratory volume (FEC). If a ratio of his FEV/FVC is less than 0. 70 after a bronchodilator treatment, he has airflow limitation (Global Initiative for Chronic Obstructive Lung Disease, Inc. , 2013). Treatment Plan For this patient, I will have a short-term and long-term treatment plan. His short-term plan will involve relieving his shortness of breath and improving his oxygen saturation (Booker, 2005).

If his FEV/FVC ratio is low, we will need to provide immediate treatment in the office. Long-term treatment involves managing his blood pressure with an anti-hypertensive medication that does not have adverse effects related to his COPD. For long-term management of his COPD, we will need to focus on medically managing his symptoms and preventing exacerbations and infections (Booker, 2005). Lastly, he needs to receive education about his disease and the risk factors he can control to minimize his symptoms. Prescription Plan My immediate goal for this patient is to relieve his shortness of breath and improve his oxygen saturation.

I will give him a 5mg/mL albuterol nebulizer treatment to help open his breathing passages and facilitate removal of his secretions (Global Initiative for Chronic Obstructive Lung Disease, Inc. , 2013). Ten to fifteen minutes following the nebulizer treatment, I will obtain the spirometric measurements. In addition, I will obtain another oxygen saturation. Hopefully, these numbers will improve as a result of the bronchodilation from the nebulizer CASE STUDY: MN 553 UNIT 7 4 treatment. For his hypertension, I will have him stop the atenolol, and I will switch him to diltiazem (Cardizem SR) 180mg PO daily.

Diltiazem is a calcium channel blocker that will not stimulate bronchospasm and is a great first-line treatment for hypertension (Gutierrez, 2008). If is sputum specimen tests positive for bacteria, he will need an appropriate antimicrobial. For his COPD, I will start him on ipratropium (Atrovent) 1 – 2 puffs every 4 hours via metered-dose inhaler (MDI) with a spacer for 48 hours. Ipratropium is an antimuscarinic drug that produces a site-specific bronchodilation in large airways (Gutierrez, 2008). It is an ideal treatment for bronchospasms brought on by the use of beta-blockers (Gutierrez, 2008).

The most common side effect of ipratropium is dry mouth (Global Initiative for Chronic Obstructive Lung Disease, Inc. , 2013). Because of its anticholinergic effect, ipratropium should be used cautiously in patients with glaucoma or bladder neck obstruction (Gutierrez, 2008). There are no major drug-to-drug interactions with ipratropium. After 48 hours, I will reassess the patient’s oxygen saturation and spirometric measurements to determine if the ipratropium has made any improvement. If he is improving, I will continue with a dosage of 1 – 2 puffs every 4 hours, not to exceed 12 puffs in a 24-hour period. An alternative to ipratropium could be theophylline (Theo-Dur).

Theophylline is a methylxanthine that relaxes smooth muscle and lessens diaphragmatic fatigue (Gutierrez, 2008). However, theophylline is not as effective in producing bronchodilation, and the chance of toxicity increases with age (Global Initiative for Chronic Obstructive Lung Disease, Inc. , 2013). Education Plan Education for this client begins with explaining the contraindication of using beta-blockers with a beta agonist. He needs to understand how to use the MDI with the spacer for his ipratropium. MedlinePlus (2013) gives a list of instructions and guidelines for care of an CASE STUDY: MN 553 UNIT 7 5.

MDI with a spacer. Since ipratropium is used for preventing a bronchospasm and not for emergency management, he may still use his albuterol rescue inhaler for flare-ups. Since ipratropium may cause dry mouth, I will encourage good oral care and hydration. The COPD Foundation (2013) has a series of educational videos for the patient and his family to watch and learn about his disease process and his medications. A follow-up appointment will be scheduled after two days to evaluate the effectiveness of his medications.

Other Interventions In addition to medical management of his symptoms, there are some other interventions, which may be beneficial for this patient. Smoking contributes to 85 – 90% of deaths from COPD (American Lung Association, 2011). A smoking cessation program along with nicotine patches may be helpful for this patient.

To help prevent infections, he should consider an annual flu vaccination and a pneumococcal vaccination every ten years. Pulmonary rehabilitation may be of help to this patient. There is significant improvement in overall health in patients after 3 months who participate in pulmonary rehabilitation programs (Global Initiative for Chronic Obstructive Lung Disease, 2013).

While in pulmonary rehabilitation, he may learn about breathing techniques, nutrition, and how to cope with his disorder (COPD Foundation, 2013). Summary This case describes a 60-year-old man presenting with complaints of productive cough and shortness of breath for 2 weeks. He has a history of hypertension and COPD. His medications may be contributing to his difficulty breathing. Further assessment of his lab work, a chest x-ray, a sputum specimen, and spirometric measurements will help me formulate a prescription plan for this patient.

His treatment plan involves immediate relief of his shortness of breath and long-term management of disease process with emphasis on prevention of CASE STUDY: MN 553 UNIT 7 6 exacerbation. A prescription plan for this patient involves changing his anti-hypertensive medication and adding a long-term bronchodilator. Education involves proper use of his inhaler and learning more about his disease process. Alternative interventions include smoking cessation classes, immunizations, and pulmonary rehabilitation. A follow-up visit is warranted to evaluate the effectiveness of the medications and further assess the success of his treatment plan. References:

American Lung Association (2011). Chronic obstructive pulmonary disease (COPD) fact sheet. Retrieved from http://www. lung. org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet. html Booker, R. (2005). Chronic obstructive pulmonary disease and the NICE guideline. Nursing Standard, 19(22), 43. The COPD Foundation (2013). Pulmonary rehabilitation. Retrieved from http://www. copdfoundation. org/What-is-COPD/Living-with-COPD/Pulmonary-Rehabilit ation. aspx DailyMed (2008). Proventil® HFA (albuterol sulfate): Inhalation aerosol. Retrieved from http://dailymed. nlm. nih. gov/dailymed/archives/fdaDrugInfo.

cfm? archiveid=9803 CASE STUDY: MN 553 UNIT 7 7 Global Initiative for Chronic Obstructive Lung Disease, Inc. (2013. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Retrieved from http://www. goldcopd. org/uploads/users/files/GOLD_Report_2013_Feb20. pdf Gutierrez, K. (2008). Pharmacotherapeutics: Clinical reasoning in primary care (2nd ed. ). St. Louis, Missouri: Saunders/Elsevier. MedlinePlus (2013). How to use an inhaler – with spacer. Retrieved from http://www. nlm. nih. gov/medlineplus/ency/patientinstructions/000042. htm.

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