NUR231 Drug Therapy

A 28-year-old female patient X is admitted to a hospital and is therefore under the care of a nurse. She is a confirmed diabetic and is 7 months pregnant. She complained of lower backache that continues for a long time even on doing lighter chores. She also complains of having the urge to vomit and she sometimes vomits, especially early in the morning. On physical examination the physician found out that she had a wound on her leg that was producing a foul smell and she had a cough that lacks mucus. On further inquiry, she states that she lives alone since her two children are in a boarding school and her husband works out of town.

The physician diagnosed patient X as an already known diabetic patient with a diabetic foot infection, having a dry cough and morning sickness due to her pregnancy. Therefore, the doctor recommended the following medications for treatment of the patient’s conditions:

Flucloxacillin for management of the diabetic foot infection so as to make the wound sterile, Ibuprofen to alleviate the lower backache, Pholcodiene for treatment of the dry cough presented by the patient and Promethazine to help in managing the morning sickness resulting from her pregnancy.

Pharmacotherapy

Pharmacotherapy is generally using medicinal drugs to treat a disease or alleviate its symptoms. Each drug has specific disease conditions for which it is indicated and in its right dosage. Hyperglycemic state in diabetic patients may damage the skin, blood vessels and nerves of the foot of an individual. Damaged nerves are insensitive to any pain and if their feet become accidentally cut, they may fail to realise. Such wounds provide sites for entry of bacteria that may colonize the wound and cause more infections that may worsen the situation to even warrant amputation when not treated (Romano, 2019). 

Oral Flucloxacillin at a dosage of 250mg given four times a day is thus prescribed for patient X to treat the condition. Flucloxacillin in a beta- lactam antibiotic that is resistant to beta-lactamase enzyme and is used for Staphylococcus aureus infections.  Its mode of action entails preventing the formation of the peptidoglycan’s crosslinks of gram-positive bacterial cell wall by binding to and locking the peptidases involved in crosslinking glycan molecules. This process disrupts the bacterial cell wall causing the cell leaking its content, leading to cell death and thus the bactericidal effect of the drug. The drug is indicated for treatment of dermatological and wound infections, pneumonia and in osteomyelitis. The adverse effects of the drug include diarrhea and hepatotoxicity. The drug is contraindicated in patients that are allergic to penicillin and cephalosporin, and also those with liver dysfunction problems. When combined with Paracetamol and/or Methotrexate, there is increased risk of the patient developing hepatotoxicity (Understanding Flucloxacillin Prescribing Trends and Treatment Non-Response in UK Primary Care: A Clinical Practice Research Datalink (CPRD) Study, 2016).

The patient also presented with lower back pains. Ibuprofen was indicated to manage this condition. Ibuprofen is a Nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain and inflammation. It works by inhibiting the cyclooxygenase enzyme and hence reduces synthesis of prostaglandins which in turn directly stimulate pain receptors and increase sensitivity of pain to bradykinin. It has an analgesic effect when administered at a dosage of 2400mg/day. It is used in management of pain such as toothache, back pain, strains or even in managing arthritis (Cashman, 2021). Oral or intravascular Ibuprofen is effective in closing patent ductus arteriosus in preterm infants.  When used together with antihypertensives, it can lead to a rise in blood pressure. It is contraindicated in patients who are allergic to other NSAIDs such as Aspirin, with stomach ulcers and liver disease. Its adverse effects include stomach pain, vomiting and tinnitus. Ibuprofen causes stomach bleeding and should therefore not be combined with other NSAIDs as this may worsen the bleeding to and cause stomach ulcers. Concomitant use of Ibuprofen with Aspirin may reduce the total anti-inflammatory effect.

Dry cough is mainly characterised by an absence of mucus within the cough. The doctor prescribed Pholcodiene to treat the patient for this symptom. It is an antitussive drug that is used in management of non-productive cough that causes discomfort to patient X. Upon oral administration of the drug, it is absorbed in the stomach, transported by blood to the brain where it suppresses cough reflex by acting directly at the cough center in the medulla. This will then bring relief to patient X as there will be no more cough stimulation. The drug is contraindicated in patients with kidney or cardiac failure, those with chronic obstructive pulmonary diseases and those with chronic inflammation of the bronchi (Pediatrics et al., 2021). It causes sedating effects when combined with phenothiazides and tricyclic antidepressants and such combinations should therefore be avoided (DFTB, 2020).

Promethazine is an antiemetic agent used in management of motion sickness and morning sickness in pregnancy. It is a histamine (H1) receptor antagonist that acts on afferent nerves of the vestibular system as well as within the brainstem on the nucleus of solitary tract in the central nervous system. The drug acts by locking the H1 receptors both in the vestibular nuclei and solitary nucleus of the brainstem. It can cross the blood brain barrier. It also has antipsychotic and sedative effects. It is also used in treating allergies, insomnia and anxiety. Its therapeutic effects are realised after 5 minutes when administered via intravascular route and after about 20 minutes when administered intramuscularly. In children the dosage of the drug given may also be influenced by the weight of the child. Promethazine is contraindicated in children under the age of 2 years as it may cause respiratory depression, in treatment of asthma and for unconscious patients who are in coma. Its adverse effects include anticholinergic effects such as constipation, dilated pupil, urinary retention and dry mouth, also hypotension and prominent sedation (Pharmacogenetic predictors of nausea and vomiting of pregnancy severity and response to antiemetic therapy: a pilot study, 2013).

Quality use of medicine

All medicines should be used for the right intended purpose in recommended amounts for therapeutic benefits. The healthcare provider should select medicine appropriate for the patient’s condition: instance, medications recommended for patient X were based on her presenting illnesses and were aimed towards alleviating and treating her condition (Nursing and Midwifery Board of Australia (NMBA), 2016, Standard 1.1). Quality use of medicine also entails safe administration of the drug to the patient using the right route of administration depending on the instructions found on the drug and monitoring for any adverse effects that could arise as a result of the patient using the drug ([NMBA], 2016, standard 7.1). Any adverse effects should be managed in time as they can worsen the patient’s condition: e.g., liver function of patient X should be monitored after administration of Flucloxacillin whose adverse effects include hepatotoxicity. Also, the selected medicine should provide the intended outcome. Drug overdose and under dose should be avoided as this may be fatal in cases of overdose or fail to provide the therapeutic effect in the case of under dose (Code of medical ethics of the American Medical Association, 2012).

Medication errors

These are mistakes that arise from improper medication but are preventable and may cause harm to the patient or any person using the drug. They include administering a drug to an unintended patient. A nurse is expected to crosscheck the patient’s treatment sheet while at bedside of the patient. He/she should check the patient’s identifiers such as names and patient number while at the bedside to ensure that he/she is attending to the right patient so as to avoid giving medication to a wrong patient (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2017, Standard 4). Patient’s ‘X’ demographic information should be clearly written down in her treatment sheet to avoid confusion during medication (EA, 2017).

Another common medication error is prescribing a wrong dose to the patient, either overdose or under dose. Drugs are only beneficial when given in their right dosage. Over dosages are poisonous and may affect different body systems that are vital for a patient’s survival while under dosages have low potency and efficacy and will therefore fail to provide the therapeutic effect that is needed. Patient X requires 250mg four times a day of oral Flucloxacillin to manage her diabetic foot infection. At doses higher than 250mg of the day four times a day, patient X is likely to lead to vomiting, diarrhea, and cause severe liver damage (Alrabadi et al., 2021).

Administering a drug via the wrong route is a medication error that can lead to death of the patient (Weant, Bailey & Baker 2014). For instance, drugs that need to be administered via the intramuscular route may disrupt the pumping action of the heart and blood circulation eventually cause death when administered through the intravascular route (The Optimal Choice of Medication Administration Route Regarding Intravenous, Intramuscular, and Subcutaneous Injection, 2015). In this scenario, Flucloxacillin, Ibuprofen and Pholcodiene are all given via the oral route of administration.

Also, a physician may fail to prescribe a given drug that is necessary for treatment of a patient’s condition. For instance, all the four drugs prescribed for patient X have a role to play in providing cure to the patient. Omitting any of the drugs will cause the condition for which the drug is meant to treat to persist e.g., absence of Promethazine will fail to provide relief for the morning sickness and absence of Pholcodiene in the therapy will enhance persistence of the dry cough (Senyuta & Klapatyi, 2016).

Anti-microbial stewardship

Anti-microbial agents are used to eradicate pathogens such as bacteria, viruses, parasites and fungi from the body. The drugs should thus be used for their right purpose without abuse so that their therapeutic effects can be realised and prevent drug resistance that is most common with antibiotics such as Flucloxacillin in this case (Inam, 2016). These can be achieved by educating patient X on the need to complete the prescribed dose, prescribing the antimicrobial drug only when necessary, and also monitoring any effects rather than the intended one of the antimicrobial agents (Flucloxacillin) experienced by the patient and reporting to the relevant agencies (Hettiarachchi, 2019).

Professional standards

Professional standards refer to code of behaviors that a nurse should uphold when giving medication to a patient. It is important that the physician used several assessment techniques to get accurate and relevant data from patient X ([NMBA], 2016, standard 4.2). When administering medications, the nurse should put into consideration that the patient too has his/her rights towards the medication being provided. For instance, patient X has some medication rights which should be respected by the healthcare provider as well e.g., the nurse should seek consent from her before giving her the medicines. Further, she has the right to receive explanation on what the medicines are and the reason behind her receiving the medication before drug administration commences. This is to ensure safe and quality practice of offering nursing needs ([NMBA], 2016, standard 6.1). She also has the right to be given the right medication, in the right dosage and through the right route and any adverse effects be reported to the concerned agency in the process of monitoring the patients progress ([NMBA], 2016, standard 7.1). All the prescribed drugs for patient X should be given at the right time for example Flucloxacillin should be given after every 6 hours in a day to maintain the right dosage. In this case, the nurse has responded in time to the health and well-being of patient X ([NMBA], 2016, standard 3.1).

The healthcare provider should also ensure that the drugs given to patient X are for the benefit of restoring her health and not to cause harm or worsen her condition. After administering the drugs, the nurse should record the dosages given and the time at which the drugs have been administered to prevent further administration of the drugs which will result to overdose. Any allergies to a particular group of drugs should be clearly written so that alternative drugs may be prescribed e.g., patient X should not be allergic to penicillin because the drug that is prescribed, Flucloxacillin belongs to the penicillin group of drugs. The healthcare giver should also take into consideration any other health conditions that the patient has despite the presenting illness. For instance, the diabetic nature of patient X should be included in the priorities of the nurse in providing care the nurse recognizes that patient X has greater experience of her life as well. ([NMBA], 2016, standard 2.3).

Person centered care

Patient care determines the patient’s prognosis. Patients under good management care always recover fast from their illnesses. The person with the role of taking care of the patient should therefore be well informed about the patient’s underlying condition and the help that they are expected to offer. The person should also be informed about the patient’s ailment and the treatment modalities adopted in the patients care plan. For instance, they should check for the adverse effects of the drugs used in managing the patient and intervene appropriately if any of the effects is observed.

Conclusion

In conclusion, proper medication is key to the care and well-being of the patient and also ensures their safety from probable medical errors that may arise in the course of treatment. The attendant should therefore have the necessary knowledge on the drugs being administered and observe the patient during the treatment course for any drug adverse effects ([NMBA], 2016, standard 6) & ([ACSQHC] 2017). Also, informing the patients about their care plan and the intended outcome so as to get they may cooperate with the care plan for better prognosis. On drug administration, drugs given to the patient should have a beneficial effect in alleviating their condition. They should be administered in the right doses and through the right routes of administration so that the detrimental effects of medication errors are minimized. Therefore, proper medication is a vital part in the patients care plan that should be upheld fully

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