This assessment comprises two parts: Part A - The goal is to provide professional-focused information on a medication; Part B - The goal is to provide person-centred information on a medication. As a nurse, you will be required to interpret and use pharmacotherapeutic information and reliable clinical evidence to support your colleagues and patients in the Quality Use of Medicines (QUM). You will interpret and use evidence to inform safe and comprehensive practice when designing professional-focused and person-centred medication information.
Part A: The goal is to provide professional-focused information on a medication
Consider the patient’s situation
Mrs Jane Hodges is a 50-year-old woman who was transported via Queensland Ambulance Service (QAS) to her local regional emergency department. She arrived with the following symptoms that commenced suddenly 60 minutes ago: Slurred speech, right-sided arm and leg weakness, and frontal headache. She was diagnosed with a pulmonary embolism (PE) 6 weeks ago and discharged home on oral dabigatran 110 mg bd. She has been receiving metformin 500 mg bd for the last 7 years for her type 2 diabetes mellitus (T2DM) and tolerates it well. Mrs Hodges is also on metoprolol 50 mg once daily for her hypertension. She has reduced her cigarette intake to less than 10 cigarettes per day. Mrs Hodges states she did not take any of her prescribed medications over the previous 7 days due to pain and difficulty mobilising, spending most days in bed. She is on a disability pension (she had a severe back injury 2 years ago from a car accident) and lives with her husband in a regional city in Queensland.
Mrs Hodges was ordered an urgent Computerised Tomography (CT) scan of her brain. The results showed an acute ischaemic stroke (one type of cerebrovascular accident [CVA]) in the left frontal lobe. She was noted to have a blood glucose level (BGL) of 21.5 mmol/L, blood pressure (BP) of 180/105 mmHg, and heart rate of 110 beats per minute (bpm) and irregular. Her electrocardiogram shows atrial fibrillation (AF). Mrs Hodges currently weighs 90 kg (height: 160 cm).
Following the results of the CT scan, Mrs Hodges was placed on an acute stroke pathway and met the criteria for intravenous (IV) thrombolysis. She has been ordered alteplase as per the local protocol (0.9 mg/kg, maximum of 90 mg); this was given at 0830 hours. Mrs Hodges was commenced on a basal-bolus insulin regimen, including insulin aspart (Novorapid) before each meal and insulin glargine (Optisulin) at 2200 hours (both types in cartridge form) with a supplemental insulin order 6 hourly (Novorapid) for glycemic control. The medical team charted her regular oral metformin 500 mg twice daily and metoprolol 50 mg once daily. These are to commence only after the speech pathology review and successful swallowing screening.
Criterion 1: Application of pathophysiological concepts to justify clinical decision-making
Collect cues/information
1. Your clinical facilitator has allocated you to care for Mrs Hodges. After the morning handover, you are asked to explain to the clinical facilitator the difference in pathophysiology between an acute ischaemic and haemorrhagic stroke. You are also asked to explain what factors contributed to Mrs Hodges’ ischaemic stroke (At least two factors).
2. Describe what thrombolysis is and present two reasons why Mrs Hodges might be administered thrombolysis rather than emergency clot retrieval (Removing the clot in the brain using a catheter thread up into the blocked brain blood vessels).
3. What two life-threatening complications can occur because of alteplase (Actilyse)? Please provide a brief explanation of each complication.
4. Following thrombolysis, Mrs Hodges’ BP increased to 225/125 mmHg. The doctor ordered hydralazine 10 mg IV. Explain the mechanism of action in how this medication achieves control in an emergency hypertensive crisis. You must also describe at least two considerations related to BP management when administering hydralazine.
Criterion 2: Application of pharmacotherapeutic concepts to explain safe medication practice
Process information
5. Mrs Hodges commenced a basal-bolus regime with a supplemental insulin order. Explain to your clinical facilitator how Mrs Hodges’ prescribed basal-bolus regime works to achieve glycemic control. Discuss why she might require supplemental insulin during the acute phase of her condition.
6. Explain the mechanism of action and administration (Dose and method) of alteplase for ischaemic stroke as well as its two common drug interactions that you need to be aware of to ensure safe medication practice.
Criteria 3: Evidenced based argument and justification of decisions
Identify problems/issues
You commence the night shift in the monitored Stroke/High Dependency Unit (HDU) at 2130, and the afternoon shift nurse has handed over to you that Mrs Hodges had a fall 2 hours ago in the bathroom. She started complaining of 8 out of 10 (pain score) 30 min ago and has a large haematoma on her right thigh. Her current vital signs are documented on the observation chart: Heart rate of 120 bpm, BP 150/90 mmHg, respiration 25 breaths per minute, and oxygen saturation of 95% on room air. The nurse has not attended to Mrs Hodges’ analgesic requirements at this stage as she was busy with a Code Blue emergency on the ward.
7. Apply one Principle from the Australian Code of Conduct for Nurses , demonstrating your safe care to Mrs Hodges. You do not need to describe your actions but discuss how the immediate nurse responses could change outcomes in a time-critical, potentially life-threatening situation.
Take action: As the student nurse, you decide to address Mrs Hodges’ acute pain.
8. The doctor has ordered a dose of IV morphine 5 mg stat for Mrs Hodges’ acute pain. Explain how morphine helps relieve pain by describing its mechanism of action.
You reassess Mrs Hodges’ pain score after 10 minutes and she still reports 8 out of 10 (pain score) in her right thigh. The doctor ordered a repeat dose of IV morphine 5 mg stat and reviewed it in 10 minutes time. After 10 minutes, there was no improvement in Mrs Hodges’ pain, so the doctor ordered a dose of IV fentanyl 25 microgram stat.
9. Describe the three most common adverse effects and one major hazard of IV morphine and discuss three safety considerations when administering IV morphine.
10. Discuss how IV fentanyl differs from morphine in relation to its mechanisms of action.
Part B: The goal is to provide person-centred information on a medication
Integrate the ACQHS Quality Use of Medicines principles into any of your responses below.
Mrs Hodges requires information and education about medication management before discharge. Her current medications are metoprolol, dabigatran, and Janumet XR. The endocrinologist has ceased insulin and commences Mrs Hodges on Janumet XR. Standard 3.2 of the latest version of the NMBA Registered Nurse Standards for Practice requires nurses to ‘provide the information and education required to enhance people’s control over health’ (2016, p. 4). In this section, we will be specifically focusing only on diabetes education.
Criterion 4: Application of social justice principles and the Quality Use of Medicines when describing mechanisms of action, adverse effects, benefits, risks, and management of pharmacotherapy using person-centred approaches. (approx. 500 words)
Remember: You need to use at least three QUM principles in the following questions. You may choose to use two principles in one question and the third principle in another question.
Take time to educate
11. Mrs Hodges is struggling to understand why changing metformin into this combined medication, called Janumet XR (sitagliptin 50 mg and metformin 500 mg, taken once a day). Your clinical facilitator asks what information you would give Mrs Hodges about the long-term benefits of having Janumet XR and closely monitoring her BGL. These could be related to the prevention of acute and/or chronic complications and improved quality of life (No need to describe the Janumet XR’s mechanism of action).
12. Your clinical facilitator asks what information you would provide to Mrs Hodges about taking Janumet XR following discharge. Describe at least three points for this combined medication.
13. Identify one aspect that you would have to consider in relation to social justice, explain how this could impact Mrs Hodges’ ongoing health needs, and offer one potential evidence-based solution to address this.
14. Mrs Hodges has decided to join a local gym under the guidance of an Exercise Physiologist. Identify one issue in relation to increasing her exercise that you need to discuss with Mrs Hodges. How will this issue affect her ongoing glycaemic control? Provide one strategy to address the identified issue.