Pharmacology Scenario 6

Pharmacology Scenario 6 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: Per the provider’s orders, I gave Mr. Hadley an infusion of vancomycin 1700mg in 250mL bag at 125 mL/hr. Vancomycin is an antibiotic that works to kill bacteria by making the bacterial plasma membrane weak which makes the bacteria more vulnerable to osmotic pressure changes, inhibiting synthesis of the cell wall, and inhibiting synthesis of RNA. Labs monitored: Mr. Hadley’s blood work revealed that his CRP levels were 88 (normal <10mg/L), which is indicative of inflammation. His WBC’s were also high, at 22 (normal 4-11 10^9/L) which is consistent with an infection. His creatinine level was high at 1.6 (normal 0.81.4 mg/dL) and his estimated creatinine clearance was low at 45 (normal 85-135 mL/min). Both of these values suggest impaired kidney function. His wound culture came back positive for MRSA. Calculations: I administered an infusion of vancomycin 1700mg in 250mL bag at 125 mL/hr. The provider ordered that the patient be given vancomycin 1700 mg (15mg/kg) IV over 2 hours every 12 hours. Mr. Hadley weighs 113kg. 113kg*15mg= 1695 mg needed. There are 1700 mg in each 250mL bag, and it needed to be run over 2 hours. 250mL/2hr= 125mL/hr. Note: 1695mg/1700mg=0.997, which rounds to 1 and makes the difference in the extra 5 mg over 2 hours negligible for the calculation as the end number would round to the same 125 mL/hr. Teachings: Regarding the drug vancomycin, Mr. Hadley should have been taught to report discomfort at the site of his IV, tinnitus, and adverse reactions he may experience. He was educated about the risk of kidney problems, and the need for blood work to frequently check the levels of the drug in his bloodstream. Mr. Hadley was also educated about frequent vital sign assessments, as his HCP ordered that his vitals be monitored every 30 minutes. He was educated about the need for antibiotics based on the bacteria present in his wound culture. [1] Scenario Analysis Questions PCC What priority problem(s) did you identify for Harry Hadley? Harry Hadley has an infected wound on his lower right leg which had just tested positive for MRSA, and a fever of 102F. His wound was not healing, and he was enduring an increasing amount of swelling, redness, and pain. S/EBP What potential problems could arise due to Harry Hadley’s medication regimen related to his priority problems? Mr. Hadley had been prescribed amoxicillin before his wound culture and sensitivity test results came back. Based on the results of that test, amoxicillin would not be effective at treating his infection, as it was MRSA and amoxicillin is not effective against MRSA. Taking any antibiotic when you do not need it can contribute to future resistance to the drug, and make infections more difficult to treat. Vancomycin was then prescribed. In high doses, this drug carries the risk of nephrotoxicity, colitis, leukopenia, tinnitus, dyspnea and wheezing, and GI upset. Because Mr. Hadley was being given IV vancomycin, he had the risk of developing red-man syndrome, symptoms of which include pruritus, urticaria, pain and spasm of the muscles in the chest and back, hypotension, and maculopapular rash on the neck, limbs, trunk, and face, due to the release of histamines. Red-man syndrome could have occurred if the drug was infused too rapidly. PCC/EBP Discuss the rationale of the provider’s choice to prescribe vancomycin to Harry Hadley. Harry Hadley’s wound culture showed that he had MRSA in his wound. Not all antibiotics will kill MRSA. MRSA stands for methicillin-resistant Staphylococcus aureus. Vancomycin is one antibiotic that is known to kill this bacteria. The amoxicillin that he had previously been prescribed would not have been effective at treating his infection, no matter how high the dose or how long he was taking it, because MRSA bacteria is no susceptible to amoxicillin. The provider recognized this and prescribed him a different antibiotic. S/EBP Hadley’s care. Identify potential patient safety issues related to Harry Harry Hadley’s renal function should be closely monitored through blood work to ensure that no signs of nephrotoxicity are present throughout the rest of his treatment with vancomycin. His urine output should be monitored for cloudiness and oliguria. Additional blood work should be done to ensure that the levels of vancomycin in his bloodstream are within the desired therapeutic range. Vancomycin may cause ototoxicity and tinnitus, so the patient should report any hearing loss or ringing in the ears as quickly as possible. T&C What other interprofessional team members should be involved in Harry Hadley’s care? Harry Hadley was being treated by the wound care team, a physician, and nurses. A pharmacist was consulted in the simulation, as well. Phlebotomists would be of use in this case, as Mr. Hadley will continue to need labs drawn. His primary care provider should be updated on the changes to his medical history, and he should follow up with them after he is discharged. Physical therapists may be useful in this situation if he is having a difficult time with mobility due to the injury on his leg. If he experiences tinnitus or hearing loss after being treated with vancomycin, an otologist may be helpful. [1] The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics