Question

Case Study

As a nurse working on a busy Med-Surg unit, your Nurse Manager approaches you and states that you are getting a new admission. You call to get report from the ER nurse. He gives the following information:

The patient’s name is Lisa Trowberg. She is a 23-year- old female with NKA (No Known Allergies). PMH (past medical history) significant for seizures since 15 years of age. She was being well controlled on phenytoin (Dilantin) until recently when she began to have breakthrough seizure activity. About 2 weeks PTA (prior to admission), her significant other of 18 months broke up with her. Becoming increasingly depressed with diminished appetite resulting in significant weight loss, she started taking St. John’s Wart as per a friend’s recommendation. She was brought in by ambulance for a grand mal seizure with + urinary incontinence. En route, she was given diazepam (Valium) IV x 2 doses and is now postictal. In addition, she was diagnosed with strep pharyngitis 1 day ago and was put on Amoxicillin ERT (Extended Release Tablet) 775 mg to be taken once daily by mouth. Today is day 2 of this regimen. She weighs 105 lbs.

Medications PTA (Prior to admission):

• • phenytoin (Dilantin) 200 mg po BID,
• • Amoxicillin ERT 775 mg po qd x 3 days
• • ethinyl estradiol/drospirenone (Yaz) 20 mcg/3mg 1c tablet daily according to package,
• • St. John’s Wort (Rosin Rose) 300 mg po TID,
• • Ibuprofen (Motrin) 600 mg po q6 prn fever or sore throat.

Her current V/S are BP 110/60 HR 74 RR 14 T 101.4°F

Labs: CHEM-7 Na:139 K:4.1 Cl:102 HCO3:23 BUN:18 Cr:0.7 Glu:78

Phenytoin: 5.2

Albumin 2.4

Her admission orders are:

• • V/S q4h
• • Seizure precautions,
• • NPO except for meds
• • IVF of D5 ½ NS with 20 mEq KCl/L Infuse 2.5 liters of ordered IVF over 24 h
• • Amoxicillin ERT 775 mg daily by mouth for 2 more days then discontinue
• • ethinyl estradiol/drospirenone (Yaz) 20 mcg/3mg, give 1c tab daily according to package
• • Phenytoin (Dilantin) 200 mg twice a day by mouth
• • St. John’s Wort (Rosin Rose) 300 mg orally three times per day – pt may use her own once verified by pharmacy
• • Ibuprofen (Motrin) 1000 mg by mouth q6h prn T>100.5°F

You receive the patient, admit her and begin to review your orders. Please discuss the following:

1. 1) Describe all of the medications she was ordered and what they do.
2. 2) Which, if any, medications shouldn't be given? Why?
3. 3) Are there any medication errors? Which ones and why are they wrong?
4. 4) What about her lab values? Which are normal? Which are abnormal? Discuss the meaning of the abnormal values and what implications there are for the patient and the medications being taken.
5. 5) What should the IVF hourly rate be set at?

Bonus Questions

• A. Which alternate medication(s) would you suggest to the provider to prescribe to your patient and why? (Worth ½ point)
• B. What patient teaching would you offer to this patient? (Worth ½ point)

Answer 1

1.The Amoxicillin is an antibiotic which is used to treat her infection (strep pharyngitis)

Drospirenone is a birth control pill or hormone pill which will stop ovulation and prevent conception this acting as a contraceptive pill

Phenytoin is a antiepileptic drug to control her seizure

Ibuprofen is used to treat high grade fever

St John's wort is a herbal supplement to treat depression

2.The patient should not be given the herbal supplement because this can interact with the birth control pill by reducing it effects.

3.The ibuprofen is overdosed because for fever the maximum recommended dose is 1200mg/day.Here the patient is ordered for 4000mg /day as needed

4.The normal lab values are

• Na:139(135_145mEq/L)
• K:4.1(3.5_5.5mEq/L)
• Cl:102 (90_110mEq/L)
• HCO3:23 (22_28mE/L)
• BUN:18(7_20mg/dL)
• Creat:0.7 (0.6_1.2mg/dL)
• Glucose:78(90_140mg/dL)

The abnormal range are

Phenytoin level is decreased to 5.5(10_20mcg/ml).This indicates the patient needed to take medication to stabilize the range

Albumin is decreased to 2.4 (3.4_5.5g/dL).This indicates malnutrition so it has to be addressed with adequate intake.

5.Total volume :2.5L(2500ml)

Time:24 hour

Drop factor:15gtt/min (Standard rate)

Flow rate=Total volume (ml)÷Infusion time (hr)

=2500÷24

=104.1 or 104

Ams 104 ml/hours