NR601 week 2 discussion - July 2018

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dq 1

Week 2: Polypharmacy Discussion

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Polypharmacy is a common concern, especially in the elderly.

  • List the definitions of polypharmacy you encounter in your readings. There is more than one.
  • Discuss three risk factors that can lead to polypharmacy. Explain the rationale for why each listed item is a risk factor. This is different than adverse drug reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are not a risk factor.
  • Discuss three action steps that a provider can take to prevent polypharmacy.
  • Provide an example of how your clinical preceptors have addressed polypharmacy.
dq 2

Week 2: ACC/AHA Guidelines Discussion

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Please review the following case.

Chief complaint: medication refill "ran out of medicine"

HPI:BJ, a 68-year-old AA female presents to the clinic for prescription refills. The patient also indicates that she has noticed shortness of breath which started about 3 months ago. The SOB gets worse with activity, especially when she is playing with her grandchildren but it goes away once she sits down to rest. She reports that she is also bothered by shortness of breath that wakes her up at night, but it resolves after sitting upright on 3 pillows. She also has lower leg edema which started 1 week ago. She also indicates that she often feels light headed and faint while going up the stairs, but it subsides after sitting down to rest. She has not tried any OTC medications at home. She never filled her prescriptions, which she received at her checkup 6 months ago, she did not think it was important.



Previous history of MI in 2010


2010-Left Anterior Descending (LAD) cardiac stent placement

Allergies: Amoxicillin

Vaccination History:

She receives an annual flu shot. Last flu shot was this year

Has never had a Pneumovax

Has not had a Td in over 20 years

Has not had the herpes zoster vaccine

Social history:

High school graduate, a widow with one son who loves out of state. She drinks one 4-ounce glass of red wine daily. She is a former smoker that stopped 20 years ago.

Family history:

Both parents are deceased. Father died of a heart attack; mother died of natural causes. She had one brother who died of a heart attack 20 years ago at the age of 52.


Constitutional: Lightheaded and faint with exertion.

Respiratory: Shortness of breath with exertion (playing with grandchildren and stairs). + Orthopnea

Cardiovascular: + leg and ankle swelling x 1 week

Psychiatric: Not taking medications for 6 months - "ran out"

Physical examination:

Vital Signs

Height: 5 feet 2 inches Weight: 163 pounds BMI: 29.8 BP 150/86 T 98.0 oral P 100 R 22, non-labored;

HEENT: normocephalic, symmetric. Bilateral cataracts; PERRLA, EOMI; Upper and lower dentures in place a fitting well. No tinnitus

NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. Thyroid non-palpable

LUNGS: inspiratory crackles

HEART: Normal S1 with S2 split during expiration. An S4 is noted at the apex; systolic murmur noted at the right upper sternal border without radiation to the carotids.

ABDOMEN: Normal contour; active bowel sounds all four quadrants; no palpable masses.

PV: Pulses are 2+ in upper extremities and 1+ in pedal pulses bilaterally. 2+ pitting edema to her knees noted bilaterally

GENITOURINARY: no CVA tenderness; not examined

MUSCULOSKELETAL: Heberden's nodes at the DIP joints of all fingers and crepitus of the bilateral knees on flexion and extension with tenderness to palpation medially at both knees. Kyphosis and gait slow, but steady.

PSYCH: normal affect; her Mini-Cog Score is 3. Her PHQ-9 score is 22.

SKIN: Sparse hair noted on lower legs and feet bilaterally with dry skin on her ankles and feet.

Labs:: Hgb 12.2, Hct 37%, K+ 4.2, Na+140, Cholesterol 230, Triglycerides 188, HDL 37, LDL 190, TSH 3.7, glucose 98 BUN 12 Cr 0.8


Primary Diagnosis:

Congestive Heart Failure (CHF) (150.9)

Secondary Diagnoses:

Primary Hypertension (I10)

Depression F32.3:

Obesity (E66):

Osteoarthritis (OA) (715.90)

Differential Diagnosis:

Peripheral Vascular Disease (PVD) (173.9)



Sertraline 25 mg. Take 1 tab PO QD disp#30, 1 refill

Tylenol 650 mg PO Q4 hours as needed for arthritis pain

Labs:UA; Brain natriuretic peptide (BNP); LFTs and TSH.

12-lead EKG, Chest X-ray; Initial 2D echo with Doppler; Ankle-brachial index


Congestive heart failure is caused by the inability of your heart to pump blood effectively enough to meet the demands of your body. If you think of your body as any other pump, if fluid does not move well through the system, then it will back up into other spaces. When blood backs up it puts a lot of pressure on the blood vessels, which forces fluid to leak out into the nearby tissue. With CHF, this fluid usually moves into your lungs, legs, or abdomen.

The signs of worsening CHF include decreased energy level, shortness of breath during your normal routine, increased swelling to your legs and feet, your clothes feel tight, or a wet sounding cough. Call the office if these symptoms occur.

Weigh yourself every morning at the same time. If you have a 3 pound weight gain in 24 hours, or a 5 pound weight gain over a week, you should call the office.

Exercise and maintaining a normal weight is very important. You should try to exercise at least 20-30 minutes a day, more if possible. Start slow with walking.

Decrease your salt intake. Do not add any extra salt to foods. Salt makes you retain fluid, and it makes you want to drink more fluid. Avoid fast food and prepared food as they are usually very high in sodium.

If you notice your legs swelling, elevate them up and rest. Do not drink alcohol and continue to avoid smoking or second hand smoke.

Take your medications as directed, with water. Do not stop them abruptly or skip doses.

I have started you on a medication for depression. It can take 2 weeks to start to feel it working and up to a month until you can fell the real benefits.

If you start to feel more depressed, like you want to harm yourself or others, please contact me right away or got to the ER.

Referrals: may refer based on lab results

Follow up: return to office in 2 weeks

Additional lab results:

Echo results: LVEF 39%

BNP - 682 pg/ml

Questions: You determine the medications for CHF/ASCVD

  • According to the ACC/AHA Guidelines, what is BJ's heart failure stage?
  • According to the ACC/AHA Guidelines, what medications should BJ be prescribed?
  • Does she need any additional medication given her history of MI?
  • Write her complete prescriptions using the prescription writing format.
NR601 week 2 discussion - July 2018
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    J       Hajjar,   R (2014)     of       Opinion   Drug Safety,13(1)     1517/14740338       org/10   2013 827660     an       to   external site     an       (Links   an external     to       Tammie   CareyFriday Jul     8:27pmKaley,       combination   is a     when       for   This form     will       of   and nonadherence     are       to   therapy such     use       therapy   the addition     second       blood   is not     monotherapy       preparations   provided with     of       potential   side effects     suggested       consist   a long     calcium       a   ACEI/ARB Fixed     medications       by   40% physicians     persistent       aldosterone   are under     substantial       ability   significantly lower     blood       cause   underutilization of     is       pertaining   their efficacy     Khanna,       Bibbins-Domingo,   ReferenceFontil, V     M       R   Guzman, D     R       K   Physician underutilization     medications       at   visits in     States:       Journal   General Internal     468-476       CruanyasCarla   Jul 21     really       discussion   polypharmacy You     great       term   explaining why     be       elderly   especially due     increases       drug   I agree     the       you   including drug     interactions       I   unfamiliar with     distribution       dosages   to treat     Reviewing       patient   each visit     essential       to   errors, ADRs,     pharmacy       important   maintain close     other       the   of the     order       and   duplication or     drug       that   available in     is       to   the amount     the       At   same time,     also       the   accurately understands     must       two   or they     be       dose   the medication     are       we   take to     use       Some   tools available     detection       prescribing   the Beers     the       tool   older person's     prescriptions,       or   tool to     to       This   based tool     of       encountered   of potentially     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consultation   pharmacists in     that       as   pharmacist can     primary       medications   can be     specific       fewer   reactions or     medication       used   multiple medical     an       your   preceptors have     Reviewing       at   visitPatient education     drug       drug   and how     these       L   & Nicoteri,     (2016)       Geriatric   Beers Criteria:     Nurse       for   Practitioners, 12(3),     R       a   REferral Program     primary       A   cross-sectional study     Journal       ),   206 doi:10     J       M   Sreedharan, J     M       ,   J ,     M       the   of Multiple     Views       Prevent   in Ajman,     Journal       4(2),   Heidi GarguiloHeidi     Jul       work,   just don't     use       periodical   and volume     proper       CareyThursday   19 at     enjoyed       the   common risk     polypharmacy       mentioned   your post     are       as   generally are     multiple       one   it was     four       per   thousand individuals     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Fletcher, &     Polypharmacy       rise   individuals especially     Science       results   living longer     development       that   to be     increases       nonadherence,   interactions, and     events       been   as coincident     5       medications   Scheper, Koning,     van       Taxis,   Some define     the       without   is ineffective,     duplication       by   medication (McGrath,     Hwang,       Three   factors that     to       provider   health care     may       to   prescribing cascade     of       counter   effects of     drug)       have   that those     the       week   more likely     prescribed       ails   (Projovic, Vukadinovic,     Pavlovic,       2016)   deficitLack of     is       individuals   take more     medications       lead   non-adherence or     medications       have   Studies have     an       of   individuals prescribed     chronic       take   medication as     need       medications   treat multiple     such       and   results in     full       individuals   tire of     deficits       resulting   the patient     wrong       at   wrong time,     the       Smith,   Movassaghi, Martins,     2017)       individuals   specialists such     endocrinologist,       Each   may prescribe     of       care   has prescribed     visit       or   care may     discharged       told   follow-up with     care       the   responsibility to     medications       2016)   steps to     medication       review   involve collaboration     patient       first   foremost followed     health       pharmacist   type of     help       that   not indicated     to       effect   other medications     taken       though   standardized can     asking       bring   their medications,     the       the   At which     care       each   and determine     what       for   et al…,     is       withdrawing   medications under     of       the   as optimizing     while       only   medication at     will       in   patient outcomes,     patient       close   and follow-up     symptoms       The   needs to     patient       to   for in     and       occurs   least every     for       al   2017) Adaptation     interoperative       systemHighly   electronic health     continue       challenge   health care     advancements       it   difficult to     system       with   providers A     as       a   medical history     clear       medications   prescribed and     it       travel   relocate, resulting     providers       providers   prescribing without     medical       been   that pharmacists     in       are   valuable resource     advancement       helping   close the     the       pharmacist   medications and     a       (Guharoy,   The clinical     done       the   of polypharmacy     rotation       very   polypharmacy is     is       necessary   review patient     education       evaluate   efficacy of     Many       seen   in a     brown       of   When opening     one       long   of medications     of       patient   not know     are       must   my preceptor     due       the   to educate     these       importantly   refusal to     one       patient   used to     Many       at   practice request     she       their   ReferencesBazargan, M     J       ,   M ,     ,       (2017)   to medication     older       Geriatrics,   doi:10 1186/s12877-017-0558-5Guharoy,     Polypharmacy:       problem   Journal of     741305-1306       ,   K ,     L       nursing   the care     adults       vitalsource   K ,     R       ,   C ,     B       simple   for reducing     Of       436-445   I ,     ,       Jurisevic,   , Pavlovic,     Jacovic,       Stefanovic,   (2016) Risk     potentially       older   in primary     Journal       72(1),   doi:10 1007/s00228-015-1957-1Wouters,     Scheper,       H   Brouwer, C     J       der   H ,     K       medication   in nursing     A       trial   of Internal     609-617       SubdiscussionHeidi   Garguilo Wednesday     at       just   the volume,     page       Bazargan   Guharoy articles     CareyTammie       at   Heidi, Thank     your       references   below ReferencesBazargan,     Smith,       H   Movassaghi, M     D       G   Non-adherence to     among       BMC   17 (163),     1186/s12877-017-0558-5Guharoy,       America's   drug problem     of       (17),   doi:10 2146/ajhp170404Heidi     Friday       12:25pmGreat,   don't forget     issue,       doi   be italicized     NadenikYesterday       9:31amTammie   Class,You bring     good       to   and communication     providers       I   clinicals is     be       for   So, a     see       be   to a     endocrinologist       under   same roof     can       CT   ultrasounds, PFT’s,     to       This   of course,     we       for   x-ray we     them       our   or “pod”     refer       be   to review     the       importantly,   line with     having       all   information being     the       priceless   also is     reviewing       &   2018) Having     information       system   time, provides     provides       net   caring for     (Bakshi       Bakshi,   G ,     B       record   A critical     Of       doi:10   IJA_178_18Collapse SubdiscussionBeena     Jul       Professor   class,Week 2     in       Nicoteri   Polypharmacy is     of       harmful   Per Dr     is       proper   use in     and       a   priority and     advocate       prescribing   the elderly     risks       of   prescription, the     potential       may   Polypharmacy is     of       are   for the     associated       of   medications related     prescription       over   counter or     order       for   health problems     are       of   are at     for       drug   adverse drug     potential       Risk   that can     Polypharmacy       (2016)   are multiple     factors       reactions   which may     polypharmacy       numerous   Comorbidity of     more       above   Use of     more       per   medication regime     or       medicines   day Barclay,     &       Comorbidity   6 or     conditions       Older   often have     and       requiring   provider assistance     intervention       the   prescription of     causes       use   drugs and     over       for   sleep aids     Study       in   drug use     adults       of   adults used     more       72%   older adults     nonprescription       in   scenario the     number       the   the chance     drugs       polypharmacy   increases the     drug-drug       polypharmacy   the susceptibility     healthy       states   and Nicoteri     Age       older   The polypharmacy     susceptibility       aging   disease states     functional       individual   in other     and       such   chronic obstructive,     and       Macular   Peripheral neuropathy,     system       puts   patients at     for       According   Whitman, DE     &       Inappropriate   use is     the       adults,   about 100,000     department       to   drug events     with       additional   of care     prescription       the   community-dwelling geriatric     cancer       higher   burden than     the       and   treatments often     supportive       may   the risk     effects       adult   described as     of       drugs   study found     of       a   diagnosis of     more       For   more former     a       prescription   include consideration     For       anticholinergic   listed as     medications,       on   sometimes requires     medicines       and   Terrey and     3)       administration   than 12     day,       nine   more than     per       patients   Pharmacokinetics of     involving       metabolism,   and biologic     These       mechanisms   alter the     including       aging   affected by     As       the   of drugs     increases       adverse   and other     As       scenario,   J has     and       metabolism   physiology contribute     rapid       Activities   associated with     and       cost,   of over     and       and   And all     challenges       Older   and leading     Adverse       are   of the     factors       health   in older     there       inappropriate   use associated     in       nearly   emergency hospitalizations     drug       the   age group     United       That   Can Take     Polypharmacy       &   (2018) Preventing     predicting       a   care provider’s     caring       patient   Electronic medical     are       polypharmacy   ADEs, specifically     2)       option   evaluate a     polypharmacy       include   the medication     every       the   of Beers     the       ensure   patients are     medications       comorbidities   the priority     the       providers   maintain accurate     lists       medication   to go     (e       primary   urgent care)     patient       accurate   list can     more       accurately   the integration     Provide       How   Clinical Preceptor     I       clinical   for NR     care       and   family practitioner     Choksy       clinic   that at     the       most   through accurate     The       medication   delegated to     and       preceptor   and guidance     during       instructed   bring their     including,       vitamins   herbals to     During       physical,   complete medication     and       including   new orders     list       recorded   an accurate     made       the   EMRS enhances     timely       renewals   Frassetto, Robb,     (2018)       reconciliation   every encounter     prevent       increases   quality of     Polypharmacy       inappropriate   of prescription     it       to   multimorbidity, and     status       multiple   consult to     the       health   The prevention     and       drug   are the     responsibility       health   providers The     of       elderly   prescription, an     reconciliation       along   the use     enhances       (Terrey   Nicoteri, 2016)     L       J   L (2016)     American       criteria:   for nurse     Journal       12(3),   doi: http://dx     chamberlainuniversity       1016/j   2015 1     ,       Robb,   , &     D