Toua Xiong Vsim - With Answers

Pharmacology Scenario 2: Toua Xiong Guided Reflection Questions When writing up your GRQ's, please ensure in the Scenario Analysis or Opening Questions that you include a detailed description of the medications you administered (this includes IV therapy), the labs you monitored, the calculations you completed, and the teaching you completed or was required. Meds administered: The provider entered an order for nystatin oral suspension: 500,000 units orally every 6 hours for thrush, following my assessment. Mr. Xiong was to swish this medication in his mouth for several seconds and then swallow it. Nystatin is an antifungal medication that belongs to the pharmacologic class of polyene macrolides. Nystatin works to kill yeast and fungus by binding to a part of their cell membrane, called ergosterol. This causes a disruption in the membrane, and cellular contents leak out which kills the yeast or fungus. A patient taking nystatin should be advised to continue using the drug for 2 days or more after their symptoms go away. Labs monitored: The provider ordered that Mr. Xiong have the following labs: CBC, BMP, and ABG. When I went in to see the patient, the results of these labs had just come back. The following values were abnormal: From the BMP: K+ 3.5 (normal 3.6-4.6 mEq/L), Cl- 90 (normal 101-111mEq/L), HCO3- 30 (normal 22-26 mEq/L). Toua Xiong is taking fluticasone propionate-salmeterol, which, like other beta-adrenergic agonists, may lower K+ levels. In COPD patients experiencing chronic respiratory acidosis with compensation, Cl- levels may be low. Toua Xiong’s HCO3- was high, which indicates possible renal compensation for chronic respiratory acidosis, as his body may be trying to retain HCO3- ions to counteract a low pH caused by too much CO2. From the CBC: Hb 18 (normal 13.5-17.5 g/dL), HCT 48 (normal 40-45%), platelets 500 (normal 150-400*10^9/L), WBC’s 12 (normal 4-11*10^9/L). The fact that all of these levels were elevated could indicate that Mr. Xiong’s body was working to fight off an infection. From the ABG: SaO2 91 (normal >95%). This result indicates hypoxemia, which may be caused by his COPD. COPD is known to cause reduced elasticity of lung tissue, destruction of lung parenchyma, and obstruction of the small airways, which could be impacting his ability to breathe and get enough oxygen to his tissues. The patient was placed on oxygen via nasal cannula to help ensure that his body was getting adequate oxygen. Misc test: BNP 423 (normal 0-100 pg/mL). BNP levels are known to be elevated in patients who have COPD, such as Mr. Xiong. Calculations: No calculations were necessary in this vsim. Teaching: I educated Toua Xiong on the drug nystatin, by teaching him that this medication is used to treat a yeast infection of the mouth called oral candidiasis, or thrush. I instructed him that this medication should be given into each side of the mouth, swished for several seconds, and then swallowed. I also educated Toua Xiong on the adverse effects of medications, and informed him that the inhalation medication that he has been using has the potential to cause thrush. Lastly, I educated him on the proper use of inhalation medication, by informing him that he is to fully exhale first, and then inhale through the inhalation device. I taught him that after he has used his inhaled corticosteroid, he is to rinse his mouth out with plain water. Scenario Analysis Questions PCC [1] What priority problem(s) did you identify for Toua Xiong? Toua was experiencing pain in his mouth and throat that was causing him to have difficulty swallowing, drinking, and eating. He rated his pain as 5 out of 10 on the pain scale, and stated that it began about 4 days ago. S/EBP/PCC Upon focused assessment, what was identified to be causing the priority problems listed above? Identify the underlying causes. According to the provider’s orders, I assessed Toua Xiong’s vital signs, pain level, heart and lung sounds, and the inside of his mouth. His heart rate was 98, BP 102/61 mmHg, respirations 24, SpO2 92%, and temperature 99 F. The patient rated his pain as 5 out of 10 on the pain scale, and stated that it hurts at the back of his mouth, particularly with swallowing. He stated that his pain began 4 days ago, and he would like something for the pain. Mr. Xiong reported that nothing makes the pain better, and that it is worse when eating. Upon auscultating the heart, I heard regular sounds with no murmurs. Listening to his lungs revealed some wheezing, with each side of the chest moving equally. Upon examination of his mouth, I discovered the presence of white patches that would be consistent with thrush. Thrush is a yeast infection caused by an overgrowth of candida, and is a common result of improper use of inhaled corticosteroids. Toua Xiong has a history of COPD for the last 5 years, and his current medications to treat his condition include inhaled ipratropium bromide and inhaled fluticasone propionate-salmeterol. Ipratropium bromide is a bronchodilator and anticholinergic, which opens the air passages. This medication works by blocking acetylcholine in the bronchial smooth muscles, which causes relaxation of these muscles and opening of the airways. Fluticasone propionate-salmeterol is an antiasthmatic and long-acting beta 2 adrenergic agonist corticosteroid, with anti-inflammatory activity. This drug works to relax the bronchial smooth muscles and prevent the release of mediators. This drug in particular may be responsible for Mr. Xiong’s thrush, as individuals taking this drug must rinse their mouth after inhalation in order to help prevent oral candidiasis. PCC/T&C Based on your assessment, what priority teaching does Toua Xiong need? Based on my assessment, it is my educated guess that the root cause of his thrush is improper use of inhaled corticosteroids. Toua Xiong may be able to avoid getting thrush in the future by rinsing his mouth as instructed following use of his medication.f He should also be reminded to use his inhaled ipratropium bromide first, and then follow it with the inhaled fluticasone propionate-salmeterol. This will allow the second medication to work more effectively, as his airways will be more open prior to its use.