| Course | NR 566 Advanced Pharmacology for Care of the Family |
|---|---|
| Week | 6 |
| Paper type | Medication review |
| Length | About 1,120 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Family Nurse Practitioner (FNP) |
| Updated | October 2026 |
Free sample paper for NR 566 Week 6
Medication Review: An 82-Year-Old at 48 Kilograms With Nine Medicines, Two Prescribing Cascades and a Kidney That Looks Normal on Paper, Changed in Sequence
Student Name
College of Nursing, Chamberlain University
NR 566: Advanced Pharmacology for Care of the Family
Instructor Name
Month Day, Year
Medication Review: An 82-Year-Old at 48 Kilograms With Nine Medicines, Two Prescribing Cascades and a Kidney That Looks Normal on Paper, Changed in Sequence
The Person Before the List
The patient is the composite household's grandparent, 82, a retired seamstress living with family, who walks with a cane and has had one fall this year without injury. The patient's own goals, asked at the start of the visit, are to stay steady on the feet, sleep through the night and stop needing to get up to urinate so often. The family manages the pill box. Weight is 48 kg, blood pressure 128/72 seated and 114/66 standing, and the ankles show mild swelling. Laboratory results: creatinine 0.9 mg/dL, potassium 4.9 mmol/L.
Clearance, Not Creatinine
The creatinine looks normal, but in a thin older adult with little muscle it flatters the kidneys. The Cockcroft-Gault estimate for age 82, 48 kg and female sex is about 36 mL/min. Several dosing decisions below change because of that estimate (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
Sorted by Indication
Table 1
The Medication List Sorted by Indication
| Indication | Medicine as taken | Comment |
|---|---|---|
| Hypertension | Amlodipine 10 mg each morning; lisinopril 20 mg each morning | Two agents, pressure now low standing |
| Ankle swelling | Furosemide 20 mg each morning | Started a year after amlodipine was raised |
| Low potassium on furosemide | Potassium chloride 20 mEq daily | Potassium now 4.9 on lisinopril |
| Type 2 diabetes | Glyburide 5 mg twice daily | A1c 6.4%; two low readings this month |
| Knee osteoarthritis | Meloxicam 15 mg daily | With lisinopril and furosemide |
| Sleep | Diphenhydramine 50 mg nightly, bought over the counter | Used for three years |
| Heartburn | Famotidine 20 mg nightly (reduced last month) | Mild symptoms |
| Bones | Calcium with vitamin D | No change |
Sorting by indication makes three problems visible at once: two drugs for blood pressure with orthostatic symptoms, two drugs whose only purpose is to treat the effects of other drugs, and several medicines on the Beers list for this age and clearance.
Finding the Cascades
Cascade one. Amlodipine was increased from 5 mg to 10 mg two years ago. Ankle swelling followed, a known dose-related effect of dihydropyridine calcium channel blockers. Furosemide was then added for the swelling, and potassium chloride was added for the low potassium furosemide caused. Nobody reduced the first drug. This exact sequence, calcium channel blocker followed by a loop diuretic, is a well-documented prescribing cascade in older adults (Savage et al., 2020). The concept is old: the swelling, sleepiness or cough that one drug causes gets diagnosed as something new, and the response is yet another drug (Rochon & Gurwitz, 1997).
Cascade two. Diphenhydramine is strongly anticholinergic. In older adults it causes confusion, constipation and urinary retention or overflow, and it impairs balance (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). The patient's frequent nighttime urination and unsteadiness may partly come from it, and the next step in a cascade would have been a bladder medicine. That step has not yet happened, and this review prevents it.
Other Findings
Glyburide appears among the sulfonylureas the Beers panel singles out because its lows last for hours, a risk increased by reduced clearance. Two low readings this month confirm the risk. With an A1c of 6.4%, glucose control is tighter than needed for an 82-year-old with falls.
Meloxicam with lisinopril and furosemide, at a clearance of 36 mL/min, carries a high risk of acute kidney injury, and chronic use of these agents in older adults is discouraged (American Geriatrics Society Beers Criteria Update Expert Panel, 2023).
Potassium at 4.9 mmol/L on lisinopril plus a supplement is drifting high.
What Was Not Changed, and Why
Lisinopril stays. It treats hypertension and protects the kidneys in diabetes, and the potassium rise is addressed by stopping the supplement rather than the lisinopril. Calcium with vitamin D stays. Famotidine stays for now at its already reduced dose, because one more change in the same month would blur which step caused a new symptom. Leaving these medicines in place is a deliberate decision recorded in the plan, not an oversight, and each will be reviewed again at the eight-week visit.
Changes in Sequence
Stopping five things at once would make any change in symptoms impossible to attribute and could unsettle blood pressure and glucose. The changes are therefore made in order, two weeks apart.
Step 1, today. Stop potassium chloride, given the potassium of 4.9 and the plan to stop furosemide. Stop glyburide and start linagliptin 5 mg once daily, which needs no kidney adjustment and rarely causes hypoglycemia; relaxed glucose targets are documented. Stop meloxicam and start acetaminophen 650 mg every eight hours as needed, with topical diclofenac gel to the knee.
Step 2, week 2. Reduce amlodipine to 5 mg and stop furosemide, recheck orthostatic pressures, ankle swelling and potassium.
Step 3, week 4. Taper diphenhydramine over two weeks (25 mg nightly for a week, then stop), with a sleep plan: a fixed wake time, no daytime napping after 2 PM, and a bedtime routine. Diphenhydramine is tapered rather than stopped abruptly because rebound insomnia after years of use can push a patient back to the bottle.
Step 4, week 8. Review famotidine; if heartburn remains mild, stop it.
Who Has to Be Told
The family member who fills the pill box receives a printed list showing what stops, what starts and on which date. The community pharmacist receives the same list and a request to remove diphenhydramine from the patient's over-the-counter purchases profile. The cardiologist who raised amlodipine two years ago receives a letter explaining the cascade and the dose reduction. The patient hears the plan in plain words and is asked to repeat the first step back.
The patient's own goals guide how the changes are explained. Steadier walking is linked to stopping diphenhydramine and lowering the blood pressure medicine. Better sleep is linked to the bedtime routine. Fewer night trips to the bathroom are linked to stopping the water pill and the sleep aid. Tying each change to something the patient wants makes the plan easier to accept and to remember.
Monitoring
Blood pressure lying and standing, ankle swelling, potassium and creatinine at two and four weeks. Home glucose once daily for two weeks after the glyburide change, with a call for readings under 70 or over 300 mg/dL. Sleep and nighttime urination reported by the family at each step. Falls reviewed at every visit.
References
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
Rochon, P. A., & Gurwitz, J. H. (1997). Optimising drug treatment for elderly people: The prescribing cascade. BMJ, 315(7115), 1096-1099. https://doi.org/10.1136/bmj.315.7115.1096
Savage, R. D., Visentin, J. D., Bronskill, S. E., Wang, X., Gruneir, A., Giannakeas, V., Guan, J., Lam, K., Luke, M. J., Read, S. H., Stall, N. M., Wu, W., Zhu, L., Rochon, P. A., & McCarthy, L. M. (2020). Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Internal Medicine, 180(5), 643-651. https://doi.org/10.1001/jamainternmed.2019.7087
NR 566 Week 6 instructions, in plain terms
The medication review usually asks you to evaluate an older adult's medications and recommend changes. Expect the prompt to ask about inappropriate drugs, interactions, kidney function, deprescribing and communication. Start with the person, including goals and function, before the list. Reorganize the list by indication so duplications become visible. Look for cascades, where one drug's side effect was treated with another. Estimate creatinine clearance rather than relying on a normal-looking creatinine, especially in thin older adults. Recommend specific changes in a sequence, not all at once, with tapers where needed. Say who must be told about each change, including family, pharmacy and other prescribers, and set monitoring.
How this NR 566 Week 6 example is built
The sample opens with the grandparent's goals: steadier walking, better sleep and fewer night trips to the bathroom. It estimates clearance at about 36 mL/min and then sorts the medicines in a table by indication. Two cascades are traced: amlodipine raised, ankle swelling, furosemide, then potassium, and diphenhydramine causing urinary and balance problems that could have led to a bladder drug. Glyburide, meloxicam and a rising potassium are flagged. Changes follow in four steps two weeks apart, from stopping potassium and switching glyburide to tapering diphenhydramine. A section explains what stays and why. The review ends by naming the family member, pharmacist and cardiologist who need to know, linking changes to the patient's goals and setting monitoring.
Reading the NR 566 Week 6 grading rubric
Medication reviews are usually graded on whether recommendations are actually made, whether changes are sequenced, whether clearance is estimated, whether cascades are identified and whether communication is planned. A review that lists problems and writes discuss with the provider beside each one earns little, so this sample makes specific changes. Sequencing them two weeks apart, with a taper for diphenhydramine, allows effects to be attributed and carries heavy weight. Estimating clearance shows the writer did not trust a misleading creatinine. Tracing the amlodipine cascade back to its first step shows systems thinking about prescribing. Naming who must be told, including the prescriber who started the first drug, completes the review. Citations support each change.
Common NR 566 Week 6 mistakes, and how to avoid them
The most common failure is a review that identifies many problems and recommends nothing, or hands every decision back to the provider. Another is stopping five medicines at once with no order and no tapers, which makes any change impossible to explain. Some papers cite the Beers Criteria as if the name settled the matter, without saying why the drug is a problem for this person. Many accept a normal creatinine as normal clearance in a thin older adult. Others forget to tell the pharmacy or the family. Start with goals, sort by indication, find the cascades, estimate clearance and sequence the changes. If your patient's list is different, share it, and a review can be drafted.
Get a NR 566 Week 6 example written to your instructions
Send the Week 6 case with the medication list your classroom supplies and any review template it requires, and a custom example is written to that list and returned inside 24 to 48 hours. The first one is free, and which reductions you would defend stays your own clinical judgment.
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NR 566 Week 6 questions, answered
Is deprescribing really the expected answer?
Often, though not automatically, and the reasoning is what carries the grade rather than the direction. Some reviews properly end by adding an agent that is missing, such as an overdue preventive therapy. What the week rewards is treating a removal with the same rigor as a start: an indication reviewed, a taper considered, a monitoring plan written and a review date set.
How are the Beers criteria used well?
As an argument rather than as an authority. Naming a drug as potentially inappropriate settles nothing on its own, since the criteria describe why an agent is a concern in older adults and leave the individual judgment open. The stronger paper states the specific concern, connects it to something in this patient, and then says what happens instead.
What if a medication has no documented indication?
That is a finding, and it is written up as one rather than assumed away. The realistic recommendation is to establish why it was started before removing it, since old records or another prescriber may hold the answer. Where no indication can be found and the agent carries risk in older adults, a tapered withdrawal with monitoring is a defensible plan.
Where can I find a free NR 566 Week 6 sample paper?
The nine-medicine review above, with two cascades traced and changes sequenced over eight weeks, is the complete NR 566 Week 6 sample. A review of your own patient's list can be prepared on request.
What is a prescribing cascade in the NR 566 Week 6 review?
A chain in which a side effect of one drug is treated with another drug, such as ankle swelling from amlodipine treated with furosemide and then potassium.