Question

Created by Raney Linck pg. 1 of 5 To complete this exercise, you will need: Success Packet: D (Drugs to Know), Clinical Tools: 3a-3c (Clinical Reminders), and a Drug Book. You may also find the search engine at this website useful: MEDLINEPLUS.GOV (also WEBMD.COM). ***** This assignment is due at 6:30 AM on your very first clinical (orientation) day. ***** CRITICAL THINKING EXERCISE INDU MOHAN INDU MOHAN, age 68, and her husband Pulin have come from India to visit her son Niraj and his family in Minneapolis. Mr. & Mrs. Mohan have flown over 20 hours from Mumbai. Shortly after arrival, she developed severe pain and swelling in her right thigh. She is Hindu and a vegetarian. She speaks Hindi and is semi-fluent in English (understands more than she speaks), and relies on her husband and son to translate more complicated terms and language. Admitting diagnosis: DEEP VEIN THROMBOSIS (DVT) Past Medical History: CHF, HTN, hyperlipidemia, Type II Diabetes, hysterectomy, chronic constipation, recurring UTIs, breast cancer with mastectomy in 2004. Day 1: Admitted on Sunday afternoon by a resident MD, who ordered a spiral CT of the lungs to rule out a pulmonary embolism (PE). A suspicious mass was discovered in her lung’s left upper lobe (LUL), which could be cancer. It is noted Mrs. Mohan has a UTI, so an antibiotic is ordered to start in the a.m. Today (Day 2): NPO since midnight, she is scheduled to go sometime today (could be early or late) for a video-assisted thoracoscopy (VAT) with wedge resection to remove and biopsy the mass. Niraj, a marketing director who works for Medtronics, stayed overnight and is at bedside. Pulin is at home with daughter-in-law Ritu, and they will come back soon. Vital Signs are as follows: 00:20 04:10 08:05 T 98.6 (oral) T 98.4 (oral) T 98.8 (oral) P 71 P 68 P 58 R 24 R 24 R 28 BP 158/84 BP 160/88 BP 164/90 O2 sat 94% on 2L via NC O2 sat 94% on 4L via NC O2 sat 92% on 5L via NC Created by Raney Linck pg. 2 of 5 09:00 SCHEDULED MEDS What data should you check before giving? Labs, I&Os, assessments, etc ✔ to GIVE ✔ to HOLD If held, explain why…. ASPIRIN 81mg PO daily. ATORVASTATIN (Lipitor) 20mg PO daily. ENOXAPARIN SODIUM (Lovenox) 30 mEq SQ q12hrs. FUROSEMIDE (Lasix) 40mg IV daily INSULIN Regular SQ per sliding scale. 150 – 199: 2 units 200 – 249: 4 units 250 – 300: 6 units >300: Call MD LEVOFLOXACIN (Levaquin) 1gm/100mL IV Piggyback METOPROLOL (Lopressor) 5mg IV q6hrs. MULTIVITAMIN 1 tablet PO daily. PSYLLIUM (Metamucil) 1 packet daily. OTHER MEDICATIONS MRS. MOHAN IS RECEIVING: Continuous IV: SODIUM CHLORIDE 0.9% 100mL/hr ACETAMINOPHEN (Tylenol) 650mg PO q6hrs PRN fever MORPHINE 1-2mg IV q 6hrs PRN pain ONDANSETRON (Zofran) 4mg IV q6hrs PRN nausea 1. Mrs. Mohan and Niraj ask for you to mix her Psyllium (Metamucil) with orange juice instead of water. (a) In general, can this be done? (b) Would you do it this morning – why or why not? 2. What LAB VALUE should you always check before administering Furosemide (Lasix) – and why? It is now 8:30 AM, and Mrs. Mohan’s fingerstick blood glucose is 204. She denies pain or nausea, and has not had a BM since admission. It’s time for her 9 AM meds. What will you give and what will you hold? INDU MOHAN DOB: 1-13-1947 ALLERGIES: Ciprofloxacin (Cipro) Created by Raney Linck pg. 3 of 5 3. What is the RATE & VOLUME you would need to program into an IV pump to give the Levaquin IV piggyback over the following time periods… RATE (mL/hr) VOLUME (mL/hr) Over 30 minutes Over 45 minutes Over 60 minutes Over 2 hours 4. Now, which time period would you choose to give the IV Levaquin to Mrs. Mohan this morning? a) 30 minutes b) 45 minutes c) 60 minutes d) 2 hours e) none of the above, because I held this medication. 5. What is your reasoning for the above choice of time period? 6. Mrs. Mohan is denying pain. Should you hold the ASPIRIN – why or why not? 7. Do you think it will be helpful to give Lovenox a few hours prior to Mrs. Mohan’s surgical procedure – why or why not? 8. What is the IV PUSH RATE in mL/min for … METOPROLOL (Lopressor) 5mg/5mL mL/min FUROSEMIDE (Lasix) 40mg/4mL mL/min ONDANSETRON (Zofran) 4mg/2mL mL/min (NOTE: I want you to look up the national standard in a drug book, but be aware facility protocols may differ). Created by Raney Linck pg. 4 of 5 OTHER “DRUGS TO KNOW” QUESTIONS (These questions are NOT associated with Indu Mohan scenario) 1. Glucocorticoids inhibit inflammation. (a) Explain how they improve breathing in a person with COPD (specifically, chronic bronchitis). (b) Would you administer this drug if patient was having an acute exacerbation – why or why not? 2. Why should a patient rinse his/her mouth after taking a glucocorticoid by inhalation? 3. What is the difference in PRIMARY ACTION between a Type I and Type II Calcium Channel Blocker? Which one would you hold if a patient’s HR were 52? 4. Identify the drug class by the generic name suffix. -LOL: -SARTAN: -PRIL: -DIPINE: 5. Complete the following table. Write one of the two capitalized words in each box appropriately. ACTIVATES –or– BLOCKS the… SYMPATHETIC –or – PARASYMPATHETIC response, which… INCREASES –or– DECREASES HR, Force of Contraction & BP CATHECHOLAMINES ANTICHOLINERGICS BETA-BLOCKERS 6. Which of the following does digitalis (Digoxin) - a POSITIVE INOTROPIC drug - increase? a) HR b) Force of contraction c) BP d) All of the above, because it is a sympathetic agonist. Created by Raney Linck pg. 5 of 5 OTHER “CLINICAL REMINDER” QUESTIONS (These questions NOT associated with Indu Mohan scenario) 1. TUBE FEEDING: When do you check residuals on a patient receiving continuous feeding? What amount of residual would cause you to stop the continuous feeding? What amount of water is used to flush after meds or when feeding is stopped? 2.

Answer 1

1.a) Yes, Psyllium (Metamucil) can be taken with orange juice instead of water.

2. The lab value that need to be checked before administering Furosemide are electrolytes, renal and hepatic function, serum glucose, and uric acid levels before and periodically throughout therapy. Commonly ↓ serum potassium. May cause ↓ serum sodium, calcium, and magnesium concentrations. May also cause ↑ BUN, serum glucose, creatinine, and uric acid levels.

3. The usual dose of LEVAQUIN® Injection is 250 mg or 500 mg administered by slow infusion over 60 minutes every 24 hours or 750 mg administered by slow infusion over 90 minutes every 24 hours

ANS ON TUBE FEEDING -

Residual volume every need to be assessed every 4 to 6 hours for continuous feedings and just before each intermittent feeding.

If a patient with a gastrostomy tube has a gastric residual volume of 100 ml or more, you may need to withhold feedings.

Most patients need supplemental free-water flushes to maintain adequate hydration; on average, they need 30 mL/kg of water per day, given either as free-water flushes or I.V. hydration.