Case Study Report: Pathophysiology, Pharmacokinetics, And Nursing Management Of A 76-year-old Male Patient With Chest Heaviness

Patient History and Symptoms

The patient in the given case studio is 76 years old male who is admitted to the emergency department with the history of chest heaviness. He himself took glyceryl trinitrate pump-spray with minimal relief. The patient also has issues like pale skin, diaphoretic & shortness of breathing.  The patient has been prescribed with Aspirin 300 mg, morphine sulphate IV 2.5 mg, low molecular weight heparin infusion, and fentanyl 50 mcg IV. This particular assignment discussed the present problem focusing on the pathophysiology, the pharmacokinetics associated with the prescribed medicine with the indications, the nursing management of the side effects of the medication.  The detailed information should be discussed with the patient, educating the diseased person about the interactions and the long-term effects of the medication provided in the ED will be discussed in this assignment report.

The patient has a history of chest heaviness, Angina and developed other health issues pale skin, diaphoretic and shortness of breath, at the time of arrival to the bed. He was also allergic to Amiodarone. The vital signs of the patient observed as Blood pressure; 172/86, heart rate; 103 bpm irregular, Spo2; 97 % RA, Temperature; 36.8 C tympanic, respiratory rate; 24b/min, and Glasgow Coma Scale; 15/15 – E4V5M6. Angina caused by the narrowing of blood vessels that carries blood tot eh heart muscles. This occurs when there is an improper balance between the Oxygen demand of heart and the supply. This results due to the increased demand and reduced supply of air (Lee et al., 2015). Angina is not usually stabling or sharp, however, the patient may feel chest pain, which is often relieved by glyceryl trinitrate, as Mr Ferguson experienced. The side effects of glyceryl trinitrate are swelling of eyes, headache, excessive sweating, chest pain, pale skin, and difficulty in breathing. Mr Ferguson also had these symptoms (Denison et al., 2017). The pale skin occurs as due the reduced blood supply and air. Excessive sweating occurs because of fear at the time of pain as the patient may feel like heart attack due to lack of oxygen and blood supply to the heart muscles. It can also be caused by pain relief medication like glyceryl trinitrate and chest pain. Both fear and side effects of prescribed medication are responsible for excessive sweating in the case of Mr Ferguson (Bril, Breiner, Perkins, Zochodne, & Diabetes Canada Clinical Practice Guidelines Expert Committee, 2018)

Pharmacokinetics of Prescribed Medications

After the absorption, aspirin is transformed in salicylate but during the first 18 to 20 minutes in oral administration, aspirin is in the predominant state of the drug in the plasma. Aspirin is than attached to the plasma proteins, and distributed widely. The concentration of plasma-aspirin is reduced instantly, as the concentration of the plasma salicylates is increased. The complex of plasma-salicylate is then rapidly distributed to the body parts. Salicylate is eliminated by the hepatic metabolism. The therapeutic indications of the aspirin include relief of a headache, migraine, sore throat, relief from influenza, rheumatic pains, fibrositis, muscular pain and aches, feverishness and lumbago (Sakurai et al., 2017). It also has antithrombotic actions which are mediated through the inhibiting the platelet activation which has been effective in secondary prophylaxis following the issues of myocardial infarction, cerebral transient ischaemic and angina problems. Therefore, this medication has been prescribed to Mr Ferguson (Sakurai et al., 2017).

Morphine Sulphate IV 2.5 mg is administered intravenously is the rapid absorption route. The half-life of this drug is 2 to 3 hours after the administration is widely distributing to the body especially in kidneys, lungs, liver and the spleen, its lower concentration has appeared in muscles and brain. Nearly 35 % of drug binds to albumin and immunoglobulin is at the concentration within its therapeutic range. Its metabolic reaction includes glucuronic acid conjugation to produce the morphine 3 and 6 glucuronides. In live and intestinal mucosa, O-methylation and N-oxide glucuronide have been produced.  After the parental dose, nearly 90 percent is eliminated within 24 hours and up to 10 percent is excreted in the bile (Gordon, Stang, Heidel, Poulsen, Cebra, & Schlipf Jr, 2018). 

Heparin is the anticoagulant, which acts by inhibiting the thrombin, and by potentiating some naturally, forming inhibitor of stimulated factor X. it is generally not absorbed in the gastrointestinal tract and the sublingual sites; therefore, it is administered by injections. After injecting in the body, heparin directly attaches to the plasma protein. It is then metabolized in the liver and the non-activated metabolic products are then excreted with the urine. The half-life of this drug depends upon the doses.  It often used for deep vein thrombosis, unstable angina pectoris, pulmonary embolism, and acute peripheral arterial occlusion. It is also useful in hemodialysis and extracorporeal circulation (Dorobantu, & Bogdan, 2016).

The pharmacokinetic properties of Fentanyl 50 mg include 8 percent excretion through urine, around 80 percent of this drug molecules bind to the plasma and the clearance is 13±2 (ml/min/kg). The volume of distribution of Fentanyl drug is distributed in the body at the rate of 4.0 ±0.4 (liters/kg). The estimated half-life range if this drug is 141 to 853 minutes. The Fentanyl 50mcg drug is commonly used in low doses as the analgesia, at the time of short surgical procedures. In high doses as the respiratory depressants/analgesia in the patient needed assisted ventilation. It can also be used in combination with the neuroleptic drug as the part of the neuroleptanalgesia technique (Rauck et al., 2017). The most important therapeutic indication of this drug is that is can be used in severe pain like the myocardial infarction (Schug, & Ting, 2017). These features of this medicine may be beneficial in the case of Mr Ferguson.

Nursing Management of Side Effects

Nursing management of the patient’s condition includes assessment, oxygen implementation, and patient position. Performing accurate Assessment is the most important skill that every nurse should bring in their practice especially when the patient experiencing chest pain. A nurse should assess the vital sign of the patient. The level of side effects should be assessed accurately in order to provide treatment accordingly and report to the physician in a severe case. The breathing assessment can be done by examining how difficult it is for the patient to breath and is there any wheeze sound (Slater, Abshire, & Davidson, 2018). Providing adequate oxygen to the patient is another nursing management of adverse effects associated with the patient health condition and medication. This may solve the breathing issues and oxygen requirement of the patient and ultimately solve the issues like breathing, pale skin and diaphoretic (Hofmann et al., 2017). Forward leaning poisoning may help Mr Ferguson to breath easily as it allows the patient to use the accessory muscle and the gravitation force effect to pull the abdominal wall down and help the person to breathe comfortably (Pinna et al., 2015).

Patient education should be provided in order to the successful implementation of the treatment. He should be informed about the drug interaction and its side effects that can be seen during the treatment. This should be done when the patient is conscious and comfortable. His family should also be educated about the same for removal for future health issues. Aspirin may interact with the medication used to lower the blood pressure and may increase the side effects of methotrexate or aminoglycoside medication if used in combination with aspirin. It may exacerbate asthma and increase the blood uric level (Moore, Pollack, & Butkerait, 2015). Morphine sulfate may interact with chlorpromazine and methocarbamol, anesthetics, sedatives, CNS depressants, and alcohol (Pérez-Mañá, papaseit fontanet, Fonseca, Farré, Torrens, & Farré, 2018). Side effects include dry mouth, skin rashes, edema, palpitation and urticarial (Pérez-Mañá, papaseit fontanet, Fonseca, Farré, Torrens, & Farré, 2018). 

Heparin infusion may interact with drugs like oral anticoagulants, platelet inhibitors, nicotine, and antihistamines. The side effects that should be informed to the patient are hemorrhage, hypersensitivity with chills, fever, and urticaria. Its high doses may also cause osteoporosis (Malloy, Rimsans, Rhoten, Sylvester, & Fanikos, 2018). Fentanyl may interact with some pain medicine like pentazocine, nalbuphine, and butorphanol. It can also interact with other medicine like cimetidine, nefazodone, azole antifungals, and HIV drugs. These interactions may reduce the removal of fentanyl and its activity (Das, Biswas, Bagchi, Mukherjee, & Tripathi, 2017). Side effects should be informed to Mr Ferguson include nausea, vomiting, dizziness, headache, itching, and redness at the application site. Mr Ferguson should be informed to call the doctor in case he experiences side effects like mood changes, agitation, confusion, hallucinations, severe abdominal pain, difficulty in urination, slow heartbeat, loss of appetite, weight loss, and unusual tiredness (Das, Biswas, Bagchi, Mukherjee, & Tripathi, 2017).

Patient Education on Medication Interactions and Side Effects

 Mr Ferguson is a 76 years old male who was admitted to the ICU with the history of chest heaviness. He also developed side effects like pale skin, diaphoretic & shortness of breathing which might be the effects of glyceryl trinitrate. Aspirin is absorbed and converted in salicylate, which further attached to plasma and distributed to the body and excreted by hepatic metabolism. Morphine sulphate widely distributed in liver, kidneys, and lung. After that, it attaches to albumin and immunoglobulin, and finally excreted in bile. Heparin binds to plasma protein, metabolized in the liver, and excreted through urine. Nearly 80 percent fentanyl bind to plasma and 8 percent excreted through urine. Nursing management to deal with the side effects of medication includes assessment, providing oxygen and patient position. Aspirin interacts with medicine like BP lowering drugs, and chlorpromazine and may cause side effects like skin rashes and dry mouth. Heparin may interact with medicine such as platelet inhibitors, and antihistamines and cause the adverse reaction like fever, and chills. Fentanyl may interact with medicine including pentazocine and HIV drugs and show side effects like itching, and nausea. The patient should also be informed about the interaction of morphine sulphate with anesthetic and sedatives and its side effects like oedema, palpitation and skin rashes.

References

Bril, V., Breiner, A., Perkins, B. A., Zochodne, D., & Diabetes Canada Clinical Practice Guidelines Expert Committee. (2018). Neuropathy. Canadian journal of diabetes, 42, S217-S221.

Das, S., Biswas, D., Bagchi, C., Mukherjee, K., & Tripathi, S. K. (2017). Can promethazine in combination with sub-analgesic doses of fentanyl offer an alternative to pethidine in pain management?–An experimental study. Indian Journal of Pharmacy and Pharmacology, 4(2), 88-94.

Denison, F. C., Norrie, J., Lawton, J., Norman, J. E., Scotland, G., McPherson, G. C., & Peace, M. (2017). A pragmatic group sequential, placebo-controlled, randomised trial to determine the effectiveness of glyceryl trinitrate for retained placenta (GOT-IT): a study protocol. BMJ open, 7(9), e017134.

Dorobantu, M., & Bogdan, S. (2016). Unfractionated heparin or low-molecular-weight heparin in the elderly. International journal of cardiology, 222, 1084-1090.

Gordon, E., Stang, B. V., Heidel, J., Poulsen, K. P., Cebra, C. K., & Schlipf Jr, J. W. (2018). Pharmacokinetic evaluation and safety of topical 1% morphine sulfate application on the healthy equine eye. Veterinary ophthalmology.

Hofmann, R., James, S. K., Jernberg, T., Lindahl, B., Erlinge, D., Witt, N., & Ravn-Fischer, A. (2017). Oxygen therapy in suspected acute myocardial infarction. New England Journal of Medicine, 377(13), 1240-1249.

Lee, B. K., Lim, H. S., Fearon, W. F., Yong, A. S., Yamada, R., Tanaka, S., & Tremmel, J. A. (2015). Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease. Circulation, 131(12), 1054-1060.

Malloy, R. J., Rimsans, J., Rhoten, M., Sylvester, K., & Fanikos, J. (2018). Unfractionated Heparin and Low-Molecular-Weight Heparin. In Anticoagulation Therapy (pp. 31-57). Springer, Cham.

Moore, N., Pollack, C., & Butkerait, P. (2015). Adverse drug reactions and drug–drug interactions with over-the-counter NSAIDs. Therapeutics and clinical risk management, 11, 1061.

Pérez-Mañá, C., PAPASEIT FONTANET, E. S. T. H. E. R., Fonseca, F., Farré, A., Torrens, M., & Farré, M. (2018). Drug interactions with new synthetic opioids. Frontiers in pharmacology, 9, 1145.

Pinna, G. D., Robbi, E., La Rovere, M. T., Taurino, A. E., Bruschi, C., Guazzotti, G., & Maestri, R. (2015). Differential impact of body position on the severity of disordered breathing in heart failure patients with obstructive vs. central sleep apnoea. European journal of heart failure, 17(12), 1302-1309.

Rauck, R. L., Oh, D. A., Singla, N., Koch, C., Parikh, N., Nalamachu, S., & Vetticaden, S. (2017). Pharmacokinetics and safety of fentanyl sublingual spray and fentanyl citrate intravenous: a multiple ascending dose study in opioid-naïve healthy volunteers. Current medical research and opinion, 33(11), 1921-1933.

Sakurai, Y., Shiino, M., Horii, S., Okamoto, H., Nakamura, K., Nishimura, A., & Sakata, Y. (2017). Pharmacokinetic drug–drug interactions between vonoprazan and low-dose aspirin or nonsteroidal anti-inflammatory drugs: a Phase 2, open-label, study in healthy Japanese men. Clinical drug investigation, 37(1), 39-49.

Schug, S. A., & Ting, S. (2017). Fentanyl formulations in the management of pain: an update. Drugs, 77(7), 747-763.

Slater, T., Abshire, M., & Davidson, P. (2018). Assessment of breathlessness: A critical dimension of identifying cardiovascular disease. Australian Nursing and Midwifery Journal, 25(9), 36.