NR 324 Week 7 Medication Management Case Example

Medication Management Case: Eleven Entries, a Dizzy Spell and a Pill Skipped Every Sunday in a 78-Year-Old Retired Seamstress

Student Name

College of Nursing, Chamberlain University

NR 324: Adult Health I

Instructor Name

Month Day, Year

Medication Management Case: Eleven Entries, a Dizzy Spell and a Pill Skipped Every Sunday in a 78-Year-Old Retired Seamstress

The Case

Mrs. R. is 78, a retired seamstress who lives alone, admitted overnight for observation after she became dizzy getting up from her armchair and caught herself on the doorframe. She did not fall or hit her head. Her lying blood pressure is 138/78 with a pulse of 64; after 3 minutes standing it is 112/64 with a pulse of 70, and she says the room "goes gray." Her INR this morning is 3.6. Her potassium is 3.3 and her creatinine 1.3, up from 1.0 six months ago. She brought her pill bottles in a shopping bag. The analysis below reads the list before the complaint, because what is on the list decides what has to be assessed first.

The List, Entry by Entry

Table 1 accounts for each entry: why it is there, what it is doing to her now, and what would show first if it were doing too much.

Table 1

Mrs. R.'s Medication List Read as Evidence

Note. Doses are from her bottles and the pharmacy record. Target INR is from her anticoagulation clinic card.

Pairs, Clashes and Duplicates, Ranked

Four problems on the list matter, ranked by what could happen to Mrs. R. First, ibuprofen with warfarin at an INR of 3.6. Her INR is above range and she is taking an over-the-counter anti-inflammatory several times a day. The combination raises the risk of bleeding, particularly from the stomach; Holbrook et al. (2005) reviewed warfarin interactions and identified anti-inflammatory drugs among those that increase bleeding risk. A fall on this combination, which nearly happened, could turn a bruise into a long admission.

Second, two diuretics and too little potassium. Furosemide and hydrochlorothiazide both remove potassium, and her supplement is not keeping up; a potassium of 3.3 in a woman with atrial fibrillation is a rhythm risk. The hydrochlorothiazide was added by a different prescriber for blood pressure, and no one appears to have reconciled it with the furosemide.

Third, three medicines lowering her standing blood pressure together. Amitriptyline, the two diuretics and lisinopril all contribute to the drop from 138 to 112 on standing, and metoprolol blunts the pulse rise that would normally compensate. This is the most likely explanation for the dizziness.

Fourth, two anticholinergic medicines. Amitriptyline and oxybutynin both appear on the American Geriatrics Society's Beers Criteria of medicines to avoid or use with caution in older adults, and using more than one anticholinergic at once is specifically flagged because of the added risk of confusion and falls (2023 American Geriatrics Society Beers Criteria Update Expert Panel, 2023).

What Gets Checked Before Anything Is Given

Before warfarin tonight: today's INR of 3.6 reported to the provider; warfarin held until the provider responds, per the unit protocol for an INR above range.

Before the morning diuretics: potassium and creatinine from this morning reported; lying and standing blood pressure taken; furosemide and hydrochlorothiazide given only if the provider confirms after seeing the orthostatic readings.

Before metoprolol: apical pulse for a full minute; held and reported if below 55.

Before amitriptyline tonight: asked whether she has felt groggy in the mornings; the provider asked whether it can be tapered, given the dizziness.

Ibuprofen: not given in hospital; the bottle taken home by her son, with her permission.

After each change: standing blood pressure every morning; potassium repeated tomorrow; INR repeated in 2 days.

The Pill Skipped Every Sunday

While going through the bottles, Mrs. R. mentioned that she does not take her furosemide on Sundays because she sits through a two-hour church service and cannot get to the bathroom. She has done this for a year and assumed it was harmless. This is not a failure on her part. A water pill taken at 8 a.m. before a 10 a.m. service is a schedule nobody could keep comfortably, and the nursing response is to ask the provider whether the dose can be taken after she gets home on Sundays, not to lecture her about adherence. Her honesty also explains part of her ankle swelling pattern, which she says is worse on Mondays.

Summary

Mrs. R.'s dizziness is not a mystery once the list is read as evidence. Three drugs lower her standing pressure, a fourth stops her pulse from compensating, two diuretics are emptying her potassium, and an over-the-counter anti-inflammatory is sitting on top of a warfarin level already above range. The nursing work is to hold what the numbers say to hold, report the clashes in order of danger, and ask for a single reconciled list before she goes home.

Before discharge, the nurse will go through the reconciled list with Mrs. R. and her son, bottle by bottle, setting aside anything stopped in a bag for the pharmacy to dispose of, and writing the new Sunday furosemide time on the pill organizer lid. She will be asked to name the one pain reliever she may use, acetaminophen, and the three signs that mean calling: dark stools, new bruising, and dizziness on standing that has not improved in a week.

References

2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Holbrook, A. M., Pereira, J. A., Labiris, R., McDonald, H., Douketis, J. D., Crowther, M., & Wells, P. S. (2005). Systematic overview of warfarin and its drug and food interactions. Archives of Internal Medicine, 165(10), 1095-1106. https://doi.org/10.1001/archinte.165.10.1095