NR 519 Week 4 Medication Review Read Backward Example

Medication Review: Reading Mr. L.'s Eight-Item List Backward Into the Processes It Was Written Against, From an Antifibrotic to a Rescue Inhaler Nobody Can Explain

Student Name

College of Nursing, Chamberlain University

NR 519: Adv Nursing Practice Across the Health Continuum: Health Assessment, Pathophysiology, & Pharmacology

Instructor Name

Month Day, Year

Medication Review: Reading Mr. L.'s Eight-Item List Backward Into the Processes It Was Written Against, From an Antifibrotic to a Rescue Inhaler Nobody Can Explain

The List

Mr. L., 66, half a year into life with pulmonary fibrosis, arrives at a new primary care practice with a medication list written by his pulmonologist and his previous primary care clinician. The list, as reconciled with his pill bottles, is: nintedanib 150 mg by mouth twice daily with food; loperamide 2 mg by mouth as needed for loose stools, up to 8 mg a day; omeprazole 40 mg by mouth daily before breakfast; atorvastatin 20 mg by mouth daily; oxygen 2 L/min by nasal cannula with exertion; albuterol inhaler 2 puffs every 4 to 6 hours as needed; vitamin D3 1,000 units daily; and acetaminophen 650 mg as needed for pain.

The purpose of this review is not to second-guess each prescriber. It is to read each entry as a statement about Mr. L.'s body: what process was someone treating, preventing or watching for when they wrote it? Read that way, the list is a physiological history.

Nintedanib: A Statement That the Fibrosis Is Being Slowed

Nintedanib is an oral inhibitor of several tyrosine kinases, including receptors for growth factors that drive fibroblast proliferation and survival. Its presence says that the prescriber accepted the diagnosis of idiopathic pulmonary fibrosis and decided the disease should be slowed, since antifibrotics do not reverse existing scar. In two phase 3 trials, nintedanib reduced the annual decline in forced vital capacity by about 94 to 125 mL compared with placebo (Richeldi et al., 2014). The entry therefore tells a nurse what to measure: lung function over time, not symptom relief this week.

It also carries obligations. Diarrhea was the most frequent adverse effect in the trials, and liver enzyme elevations can occur, so liver tests are monitored. The list should say when his last liver tests were done; it does not.

Loperamide: A Statement About the Nintedanib

Loperamide appears because of the entry above it. It says that nintedanib has caused loose stools and that someone chose to manage them rather than reduce the dose or stop the drug. That is a reasonable choice, but it means the diarrhea is ongoing. A nurse reading this entry should ask how often he takes it, whether he is losing weight and whether he is drinking enough, since dehydration from diarrhea can harm the kidneys and leave him more breathless.

If the diarrhea cannot be controlled, the list may change in a way the nurse should anticipate. The other approved antifibrotic, pirfenidone, slowed decline in lung function and exercise capacity in its phase 3 trial, with gastrointestinal and skin-related adverse events more common than with placebo (King et al., 2014). Its skin effects include sensitivity to sunlight, which would matter for a man who, as he mentioned, spends mornings gardening. A switch between antifibrotics would therefore bring a new set of teaching needs, and the review notes his outdoor habits now so that the next prescriber has them.

Oxygen With Exertion: A Statement About the Barrier

Oxygen prescribed only with exertion is a precise statement about his lungs: his resting saturation is acceptable, but it falls during activity, the pattern expected when a thickened alveolar wall limits oxygen transfer as blood moves faster. The prescription will need revision as the disease progresses, and the first sign will be desaturation at lower levels of effort.

Omeprazole: A Statement About Symptoms, Not About the Fibrosis

Reflux is common in people with pulmonary fibrosis, and it was once thought that treating it might slow the lung disease. The 2022 international guideline suggests against using antacid treatment for the purpose of improving respiratory outcomes in idiopathic pulmonary fibrosis (Raghu et al., 2022). Omeprazole on this list is therefore best read as treatment for his heartburn, which he still reports several nights a week, not as treatment for his lungs. That changes how its success should be judged: by his symptoms, not by his lung function.

Atorvastatin, Vitamin D and Acetaminophen

Atorvastatin is a statement about cardiovascular risk from his age and former smoking, unrelated to the fibrosis. Vitamin D likely reflects a low level found on past testing or concern about bone health. Acetaminophen as needed suggests some joint or muscle pain; it is a reasonable choice for a man already taking a drug that affects the liver, provided he stays within the daily maximum and his liver tests are watched.

Albuterol: The Entry That Does Not Fit

The albuterol inhaler is the one entry no current mechanism explains. Albuterol relaxes airway smooth muscle and relieves obstruction. Pulmonary fibrosis is a restrictive disease, and Mr. L.'s spirometry showed no obstruction. Read backward, the entry says someone once thought he had airway narrowing, perhaps because of the faint wheeze heard at his first pulmonary visit, or because breathlessness in a former smoker is often assumed to be chronic obstructive pulmonary disease. He says he uses it once or twice a month and is not sure it helps.

The entry should not simply be removed; it should be explained. The review recommends asking the pulmonologist whether the wheeze has been clarified and whether albuterol has any role. If there is no airway disease, the inhaler adds little and may reinforce a mistaken belief that his breathlessness is asthma-like and can be reversed.

Summary for the New Practice

Read backward, the list describes a man whose fibrosis is being slowed by an antifibrotic that is causing diarrhea, whose gas exchange falls with effort, whose reflux is still symptomatic, and who carries one inhaler from an earlier theory of his illness. Four follow-up questions come out of the review: the date of his last liver tests, the frequency of loperamide use and his weight trend, whether his reflux treatment should be adjusted for symptom control, and whether albuterol is still needed. Each is framed as a question to the prescriber who owns that decision, not as a change made at this visit. The new practice will then own a list it can explain line by line, which is the point of reading it backward.

A final note concerns what the list does not contain. There is no opioid for breathlessness, no referral for pulmonary rehabilitation recorded and no documented conversation about goals of care. None of these is required at six months, but each is a question the new practice can raise early, while it is easy to raise.

References

King, T. E., Jr., Bradford, W. Z., Castro-Bernardini, S., Fagan, E. A., Glaspole, I., Glassberg, M. K., Gorina, E., Hopkins, P. M., Kardatzke, D., Lancaster, L., Lederer, D. J., Nathan, S. D., Pereira, C. A., Sahn, S. A., Sussman, R., Swigris, J. J., & Noble, P. W. (2014). A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. New England Journal of Medicine, 370(22), 2083-2092. https://doi.org/10.1056/NEJMoa1402582

Raghu, G., Remy-Jardin, M., Richeldi, L., Thomson, C. C., Inoue, Y., Johkoh, T., Kreuter, M., Lynch, D. A., Maher, T. M., Martinez, F. J., Molina-Molina, M., Myers, J. L., Nicholson, A. G., Ryerson, C. J., Strek, M. E., Troy, L. K., Wijsenbeek, M., Mammen, M. J., Hossain, T., . . . Wilson, K. C. (2022). Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: An official ATS/ERS/JRS/ALAT clinical practice guideline. American Journal of Respiratory and Critical Care Medicine, 205(9), e18-e47. https://doi.org/10.1164/rccm.202202-0399ST

Richeldi, L., du Bois, R. M., Raghu, G., Azuma, A., Brown, K. K., Costabel, U., Cottin, V., Flaherty, K. R., Hansell, D. M., Inoue, Y., Kim, D. S., Kolb, M., Nicholson, A. G., Noble, P. W., Selman, M., Taniguchi, H., Brun, M., Le Maulf, F., Girard, M., . . . Collard, H. R. (2014). Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. New England Journal of Medicine, 370(22), 2071-2082. https://doi.org/10.1056/NEJMoa1402584