Case Analysis:

Drug Therapy and Patient Data Interrelationships

(v2)


           

 

The following case and analysis and related links are intended to illustrate how assessment data can be used in

planning, monitoring, and evaluating current and future drug therapy. It helps the reader to view clinical data from the

lens of one who is responsible for:

prescribing medications,

preventing and minimizing drug adverse effects and interactions,

insuring optimal adminstration of the medication,

and monitoring and evaluating the patient for therapeutic and adverse drug effects.

 

The case uses the Functional Health Patterns as the framework for assessment.

Relevant data that should be included also are included in the analysis section.

 

Click on the underlined links to obtain further information about the patient assessment data.

 

Case C. G.


                  (Adapted from case and analysis by A. borden and K. McWha)

I. Demographic/Personal Information

I. Demographic/Personal Information
Analysis/Comments

Age: .66 years old Sex: Male

Current residence: Boston, Massachusetts

Place of birth: New York City.

Marital status: widower

Educational level achieved: college graduate

Employment status: retired; former manager of small business; works part-time in a garden shop.

Medical diagnoses: hypertension, hypercholesterolemia, post-cva

Allergies: Patient states he is allergic to aspirin-"it upsets my stomach"

 

 

Age is a factor in deciding which drug to prescribe.(the WHO recommends that Tenormin not be used for older adults, age 60 or older.)  Marital status is important, because a partner may be included in teaching about the drug , side effects, and toxic effects.  The educational level is a factor to consider in the method of teaching about the drug, the depth of detail of information taught and the simple and technical language used.  The medical diagnosis is important, in deciding the drug therapy and results desired.  It is indicated that the patient had a hypertension post CVA, therefore a antihypertensive is indicated, the hypercholesteremia is important, since it may be a contributing factor to atherosclerosis, which is a risk factor for CVA and HTN.
             Missing information from the nursing history, is a complete review of the symptoms, past medical history, current drug therapy, or over the counter medications used.  These are very important pieces of information, because Tenoretic should be used cautiously with patients with asthma.(Even though it contains Tenormin, a cardioselective B, receptor blocker, it  may also affect B2 receptors in the respiratory tract.)  Tenoretic is metabolized in the liver, and is excreted by the kidneys, so it should be used cautiously if a patient has liver or kidney dysfunction, and the dosage may need to be reduced.  Since Tenoretic causes a reduced heart rate, it is contraindicated with patients having bradycardia.  The complete vital signs reports missing, with pulse being especially important to monitor throughout therapy.  Also, the patients allergies are not identified.
            The patient's allergies are important to identify, because hypersensitivity to sulfonamide desired drugs may be predictive of possible hypersensitivity to Tenoretic. The patients allergies are identified but need further exploration as to whether a true allergy or a side effect.The patient's allergies are important to identify, because hypersensitivity to sulfonamide desired drugs may be predictive of possible hypersensitivity to Tenoretic.  In addition, the history should include if the patient has had a history of anaphylactic reactions to a variety of allergens, because they have a  more severe reaction on repeated challenge, either accidental, diagnostic or therapeutic, and may be unresponsive to the usual dose of epinephrine used to treat the allergic reaction, while taking a beta blocker. 
            Also missing are the other medications (over the counter drugs also) and use of herbal medicines or health supplements, since drug interactions could occur.  A complete baseline blood profile is missing, such as CBC, electrolytes, BUN  and Creatinine, glucose, and liver enzymes.  These need to be monitored while on Tenoretic is a combination of Atenolol, (the Beta blocker), and Chlorthalidone, (the thiazide derivative).  The Chlorthalidone component can cause and increase loss of water, potassium, magnesium, and sodium, the most concerning being the K and Mg.  The Tenormin component may contribute to hypo or hyperglycemia. 
            The information taught to the patient is missing, and the patient's understanding of side effects, adverse reactions, and potential electrolyte imbalances is not presented.  This can be vital because a toxic reaction or adverse reactions could be detected early, and medical intervention should be initiated before permanent problems occur.  (Adverse effects include: difficulty breathing, cold hands or feet, mental depression, skin rash, swelling of the ankles, feet or legs, slow pulse, headache, dizziness, nausea/vomiting, diarrhea, unusual tiredness or weakness, disturbed sleep, decrease sexual ability, and hypotension.)

2. History of Present Illness

History of Present Illness
Analysis/Comments

Five years ago: Sought medical attention because writing became smaller and unable to arrange flowers with left hand. Client knew what to do but physically could not perform the actions. Blood pressure at that time: 225/120. Was hospitalized with diagnosis of CVA and placed on Tenoretic 50 mg po daily and Klor Con 10 1 tab  po daily.


Five years ago: Joined health club. Complained of numbness of mouth. Hospitalized with diagnosis of TIA post CVA. Placed on IV therapy with potassium for 2 days. Discharged on Tenoretic 50 mg po daily and Klor Con 10 1 tab po daily. BP stable at 130/76.

Past 4 years: Regular primary care clinic visits every six months.

Three months ago: medication changed to: Tenormin 100 mg po daily; Niacin 3,000 mg po TID; and Bufferin 500 mg daily. Continues with regular primary care visits every six months.
 
 

The history of the present illness was too brief, with no indication of the cause of CVA-(hemmorrhagic, embolic, thrombolytic), and no information about any similar previous events.  Missing is information of suddenness of the episode, if a headache was experienced, and the complete neurologic exam was missing.  The drug treatment is markedly different if there is a infarct vs. a bleed or embolus; if there is an infarct, anticoagulants may be indicated; if there is a hemorrhage, medication to control HTN and diuretics to control ICP may be indicated initially if embolus, pursuit of the source, possibly cardiac, may indicate need for an antiarrythmia. 
            The physical symptoms are important, and any residual deficits should be indicated, because they may impact upon the persons ability to understand the drug therapy, and his ability to take the medication as prescribed.
            It is important to know that he was prescribed Klor Con daily, yet when admitted with numbness of the mouth and a dx of TIA, his K+ level must have been low, because of reported IV Potassium administration.  This brings in to question whether or not he was taking his medication as prescribed,  if he wasn't if this may have contributed to having a TIA and hypokalemia.  Missing data, again, are the other electrolyte levels, the complete vital sign report, (especially heart rate).
            In October of 1990 his medication was changed to Tenormin 100 mg daily, (therefore the diuretic component of Tenoretic no longer a concern, and no further need for Klor Con supplements)with the Niacin 3000 mg ordered, this suggests a continued problem with hypercholesterolemia, since Niacin causes a decreased plasma cholesterol and triglycerol.  The lab data is missing, such as the cholesterol level and ratio of HDL/LDL.  The Bufferin is important because it could be prescribed to decrease the flushing that is a common side effect of niacin therapy, or may be used for its anticoagulant properties.  Missing is the review of symptoms, lab values, and vital signs at each entry of clinic visits.y be used for its anticoagulant properties.  Missing is the review of symptoms, lab values, and vital signs at each entry of clinic visits.The cholesterol readings should be assessed to determine if it would be desireable to change him to a statin drug to lower lipids and for additional cardiovascular benefits.


 

 
3. Functional Health Pattern Assessment (click here for discussion of how the assessment of functional health patterns relates to drug therapy and how drug therapy may affect the patterns)

Patient Data
Analysis/Comments
3.1 Health perception-health belief pattern: Maintains medication regimen. No known variables preventing health maintenance at this time. No colds within the past year. Walks 4 miles daily for exercise. Smokes 1/2 pack of cigarettes daily and drinks socially. Unable to define specific illness. Seeks health care for alteration in perceived health status.

The importance of maintaining the medication regime is highlighted, because treatment with blockers must never be stopped quickly, since rapid withdrawal may precipitate cardiac arrhythmias.  One factor that could be considered is whether the Tenormin is contributing to the hypercholesterolemia, because one adverse effect of the drug is that triacylglycerol levels may increase.  It is important that he walks four miles daily for exercise, because exercise is important in cardiovascular conditioning in reducing high BP.  The fact that he smokes a half a pack of cigarettes daily is significant, because it is a serious risk factor for HTN, and needs to be addressed with the patient.  The nicotine could also interact with his B blocker and case adverse effects.  Missing information is the amount of alcohol consumed while taking Atenolol.  It is concerning that he is "unable to define specific illness", because his HTN has had serious consequences, and he is taking a medication with potentially serious side effects and adverse reactions.  There needs to be more information as to whether a residual cognitive impairment is the cause of his lack of awareness or denial,  or lack of exposure to the information.  It is also noted that he "seeks health care for alterations in perceived health status", which if he is unaware of the specifics of his illness and drug therapy, could mean that he seeks health care to late.  He needs to fully understand the potential adverse reactions, and seek care experiencing these.  He should be monitoring his pulse at home, and notifying the health care provider if his pulse slows to 50 bpm or slower,  even if he is feeling well.  (This could prevent the potential adverse reaction of cardiac failure due to Tenormin.) 

His immunization status should be noted: tetanus (especially because of his gardening and floral shop activities), influenza, and pneumonia.His use of or exposure to herbicides, especially organophostates, should be explored. These may cause liver toxicity and/or affect microsomal enzyme activity which could alter drug biotransformation.

 
3.2 Nutritional metabolic pattern: Eats 3 meals daily. Maintains a "fat free" low cholesterol diet of 2200 Kcal daily. Eats red meat two times per month. Drinks 5 glasses of water and 2 cups of coffee daily. No weight loss, gain. or loss of height. Appetite is good. No food or eating discomfort or swallowing difficulty. No skin lesions; skin is dry. Heals well. Last cholesterol: 252.
 

III.  Under nutrition-metabolic pattern, it is important that he is following a reduced fat and low cholesterol diet, because this will help to reduce his cholesterol level and then he may  no longer need the Niacin therapy in the future.  Missing is the nutritive values of his meals (it only states "three meals daily"), with information about his vitamin and mineral intake, and if he takes any daily supplements.  His plasma proteins should be drawn, because the protein binding of the drug may be reduced if he is protein deficient.  His Hematocrit would indicate if he is getting sufficient iron, since fish and poultry are high in protein, but lower in iron than red meat.  It is not mentioned whether he is on a low sodium diet or not, and a lower sodium diet could help to lower his BP, and combined with exercise,  decrease in ETOH, cessation of smoking, weight loss, and stress reduction, could decrease his need for drug therapy, or possibly require a decreased dose of Tenormin.  His coffee consumption is important, because caffeine is a drug, which could interfere with the drug therapy.  It is highlighted that he has had no weight loss or gain, because it could effect the dosage of medication required (if he had a significant change in weight), and could indicate CHF if a sudden weight gain occurs.  He should be monitoring his own intake and output, and weigh himself daily, with the awareness of this serious potential adverse reaction. 
            "Appetite is good"  also indicates that anorexia or nausea are side effects not experienced.   "No food or eating discomfort" or "swallowing difficulty" is important, because potential side effects are agranulocytosis, weakness, aching, and sore throat, laryngospasm, and dry mouth.  "No skin lesions and healing capacity is good" is important, because it suggests that the patient has good nutritional status, and is not experiencing adverse effects from the Bufferin, such as hypercoagulability and bleeding problems.  The "last cholesterol was 252" is important, because it indicates that it is still elevated (greater than 200), but missing data is the baseline level, and HDL/LDL ratio.  This is important in determining whether or not the Niacin therapy and low cholesterol diet has been beneficial.  There should be information about when he takes his medication in relation to his meals, since it is absorbed best when taken one hour before meals, or at bedtime. 
3.3 Elimination Pattern: Daily bowel elimination . No discomfort. Brown soft stool. No incontinence or laxative use. No elimination problems. Control good. Urine clear, without odor.
 
  It is important to note that his bowel movements are normal, soft, brown stool, because it indicates that he is not having the potential adverse reaction of the Tenormin of diarrhea or constipation, or with the Bufferin, of GI bleeding.  Although,  a hemocult stool specimen would be beneficial to indicate a smaller GI bleed.  Also, a side effect of Niacin is gastric disturbances, which are not apparent.
3.4 Activity-exercise pattern: States he has sufficient energy for desired activity. Regular walking4 miles daily. Hobbies include: swimming, vacation, boating, dancing, cooking, and arranging flowers. Since he indicates that "he has sufficient energy for desired activity," this indicates that he is not having the side effects of tiredness, fatigue, lethargy, or depression from the Tenormin.  Beta blockers may affect a person's abilitiy to exercise. It also supports that he is getting sufficient kcal for activities on his low fat, 2200 calorie diet.  His "regular walking 4 miles/day" indicates that he is constantly getting cardiovascular exercise, which is good for lowering BP, and has the energy and motivation to be active in his health care. 
3.5 Sleep-rest pattern: Generally rested and ready for activities after sleep. No sleep onset problems. Does not use aids. Does not take rests or relaxation periods except for vacations and days off. It is important that he reports that he feels "generally rested" and has no trouble with onset of sleep, because a side effect of Tenormin could be insomnia, or drowsiness, which he does not report having.  It is noted that he does "not rest or take relaxation periods", because stress reduction is a component of reducing BP, this might not be recognized by the patient.  Missing data are the number of hours spent sleeping per night, and the amount of dreaming experienced.  Tenormin can cause increased dreaming as a side effect.
3.6 Cognitive-perceptual pattern. No hearing difficulties. Does not use hearing aid. Wears glasses for decreased vision in right eye. Short term memory loss. At times unable to locate car in parking lot. No difficulty in learning. "Wears glasses for decreased vision in right eye" is significant, because this could be a deficit from the CVA, or an unrelated problem, and also could impact his ability to take his medication.  His eye exam should be noted, and whether or not this impairment impacts his functioning.  "Short term loss" is important-the detail is missing about whether this is a deficit related to the CVA, or if it is new in onset.  If new, it could be due to ischemia to the cerebrum, and needs to be investigated.
 
Having a short term memory loss could impact his ability to recognize signs of adverse drug reactions, or in remembering whether he took his daily dose.  He could either inadvertently abruptly stop his medication, which could cause heart failure or could overdose and become toxic, and not remember that his symptoms are serious.   "Sometimes things make me angry and annoyed" seems to contradict his statement that  his life is not affected by his residual effects of his CVA.  More details need to be included about what "things" make him angry, because he could possibly be having adverse reactions to his medications that he hasn't identified, and these can be addressed.  Missing is the type of work that he does, because this could be significant in the management  of his drug therapy - if he works irregular hours and doesn't consistently take his medication, and if he has health benefits and has any trouble obtaining his medications.
3.7 Self perception-self-concept pattern: Clients states "most times I am well and feel good about myself" Client states that the following residual effects from his illness do not present a problem to him: If he is quiet and there is a sudden noise, he has no control over his left hand and his arm will fly to the side; weakness on left side when lifting; and hand writing is not as neat. Exploration of his perception of himself as having any health problems or limitations may help to determine if he is being realistic about his health. His strategies to cope with lack on control over left hand and short -term memory loss should be explored both for safety as well as abilty to self-adminsiter medications
3.8 Role-relationship pattern: Clients lives with his 80 year old mother who is independent in ADL. Their relationship is good. His mother depends on him to drive her to doctor's appointments, shopping, and household maintenance. Client states: "I have quality friends to socialize with." He enjoys his work and relates well to his co-workers. His satisfaction with his living arrangements and responsibilities for his mother should be explored for possible sources of stress. Other support systems should be identified.
 
3.9 Sexuality-reproductive pattern: Client states he has no problems and is not involved. The client should be more specifically asked if he is experiencing impotence or a lessened libido, because these are side effects of the Tenormin, and are also side effects of HTN.
 
3.10 Coping-stress tolerance pattern: There have been no major changes in client's life during past year. Client states: "I have family members and close friends available when I need to talk things over, and a network of support is available to me. There are no big problems." It is noted that he has family and close friends for support, which is often a factor in success with maintaining stress reduction and medical therapy.  Missing data is what his significant others' roles are in assisting him with the lifestyle to decrease risk factors, and how aware they are of his HTN and medication effects. 
3.11 Value -belief pattern: Client states: " I generally get what I want out of life and am looking forward to my niece's wedding. Religion is a big part of my life. " It is missing whether the patient believes that the drug therapy is effective,  and beliefs about preventive care, such as the alterations in lifestyle - (stopping smoking, decrease in ETOH, exercise, diet, stress reduction).  This could impact his future need for Tenormin and Niacin, because often, BP medication does not have to be forever, especially when lifestyle changes can drastically lower BP.  Also, his perception about when to seek medical attention could seriously impact the event of another CVA or hypertensive episode. 

 

4. Screening physical exam: Click here for discussion of physical assessment and drug therapy


Patient Data
Analysis/Comments

Well groomed, neat, and clean appearance.

Oral and mucous membrane is pink and intact with no lesions.

Client has natural teeth, no dentures, and no missing teeth.

Hearing is good. Wears glasses.

Pulse: 70 Regular rhythm and strong. Respirations 24. deep regular rhythm.

No abnormal breath sounds.

BP: 126/70. T 99 po

Hand grasp is weaker on the left side. Can pick up pencil. Writes, eats and places flowers with left had; cuts and performs other activities with right hand.

Skin is dry. No color changes or lesions.

Gait is normal. Posture is good and there are no absent body parts.

Functional ability: full self care. Weight: 184 lbs  Height 5 ft 6.5 in

Oriented to time, place and person. Able to grasp ideas and questions clearly. Speaks English. Speech and voice pattern are clear.

Eye contact is present with normal attention span.
 
 

It is important that his pulse is 70, regular rhythm and strong, respirations are 24, deep and regular, and BP=126/70.  This is evidence that the drug therapy has been effective, without causing adverse reactions - (such as bradycardia, and respiratory bronchospastic effects.) 

There seems to be no changes in his functional ability, with the residual left handed weakness apparent earlier. 

Breath sounds are important to evaluate because the beta blocker may cause wheeezing indicating possible bronchospasm from beta 2 effects.

Examination of the fundi of eyes should be done to determne any vascular changes that might indicate that hypertension has been uncontrolle

It is important that his gait is normal, since an adverse reaction to the Tenormin is dizziness, vertigo, ataxia.  Missing is orthostatic BP's, which are important because B blockers can cause postural hypotension.  Also missing is whether or not he has any pain, such as headaches or leg pain, which could be due to the B blocker also.
           

His weight of 184 lbs., and height of 5'6", is significant in evaluating his drug dosages, and also in whether it is recommended that he loose weight.  This seems to be much more than the ideal body weight for a man his height, unless he is very muscular.  (A triceps skinfold test could make the data more complete)  Weight loss, if necessary, could impact his future need for BP medication.
           

A more thorough neurological exam would be beneficial , with the results of a tool such as the MMSE to evaluate his ability to "grasp ideas clearly."  All systems could potentially be adversely affected by his drug regime.  Therefore, a thorough systems examination, especially cardiac and pulmonary, should be done.  Tests such as a baseline EKG, Chest X-ray, electrolyte, CBC levels would add more information about adverse reactions.