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HNN215 Quality Use Of Medicines Questions On the 10th July at 0900hrs, Mr. Matthew Banks, aged 45 years, fell off his motorbike whilst riding on a mountain trail. In this accident he sustained an open fracture to the right tibia which was contaminated with mud and debris. At 1600hrs on the 10th of July, Mr Banks was admitted to the surgical ward following debridement and internal fixation surgery. Mr Banks is allergic to all penicillins and cephalosporins (he experienced two episodes of anaphylaxis when he was a child) and has an adverse reaction to morphine (hallucinations). He has a past medical history of hypertension. Mr Bank’s medication chart is attached. On assessment, Matthew is resting in bed following his surgery. His right leg is elevated on a pillow and the dressing is dry and intact with nil signs of bleeding. Matthew is receiving patient controlled analgesia (fentanyl) and states that he is “very comfortable” and only has a “little bit of pain” when he moves. He feels like his mouth is “very dry” and he has not passed urine in the last six hours. The Emergency Department doctor had written up his usual medicines on the drug chart (attached), along with analgesia and prophylactic antibiotics prior to surgery. His physical assessment data is as follows: Height 187cm, weight 90kg BP 106/64mmHg Pulse 74bpm, regular Respirations 16bpm SpO2 on 6L O2 via Hudson Mask 99% Temperature 36.4 degrees Matthew’s blood tests including those related to renal function are all within normal limits. 1. a) Assess Mr. Banks’ medication chart and identify and explain two significant risks that may be associated with the use of these medicines.  b) Describe the nursing strategies a nurse may implement to prevent/manage the risks you have identified in Question 1a.   2. a) The orthopaedic surgeon has ordered post-operative intravenous Timentin 3.1g six hourly for seven days because Matthew is at risk of bone infection. Explain the benefits of regular antibiotic administration. Your answer should include reference to appropriate pharmacokinetic concepts and quality use of medicines.   b) Nurses must practice quality use of medicines, including the safe and effective use of antibiotics. Describe the role of the nurse in adhering to quality use of medicines to prevent antimicrobial resistance in the clinical setting.  Answers  1. a) Mr. bank has met with an accident and has an open right tibia fracture. He is admitted in a hospital where he will undergo a debridement followed by an internal fixation surgery. He is having symptoms that may result from the usage of these medications. He did not urinate for the last six hours and is suffering from pain when he tries to move. He is under a medication at present and is receiving patient control analgesia (fentalyn) and prophylactic antibiotics just before the surgery along with his regular medications. Fentalyn has many risk factors. The other drugs that the patient is taking along with fentalyn can interfere with the metabolism of the fentalyn and the drugs have an addictive effect on the patient (Choi et al., 2014). The dose prescribed to the patient may be too high. Fentalyn toxicity has the following symptoms like bradycardia, drowsiness, cold skin, breathing problem and dizziness.   Breathing problem is one of the two significant risks. Relaxation techniques can be adopted that can help to overcome the problem to a greater extent. Breathing exercises and rebreathing into a paper bag can also be two effective measures in the reduction of the breathing problem. The person suffering from the breathing problem should be encouraged to take sustained deep breathes by allowing the patient to yawn, encouraging slow inhalation and allowing him to use incentive spirometer.    The aminoglycoside group of antibiotics also has major risk factors on the patients. They often affect the liver and bring about renal disorders, decrease in the albumen, shock, pleural effusion and pneumonia. The use of the clindamycin may cause severe diarrhea which sometimes followed by colitis (Tosti et al., 2015). Vancomycin has adverse side effects and lead to the nephrotoxicity.   Diarrhea is another significant risk of the medications. Rehydration or the discontinuation can be adopted to cure the problem. The inciting agent can be replaced by an antibiotic which has a lower risk of causing diarrhea. Oral metronidazole can also be administered in order to reduce the drug induced diarrhea. The retention of the toxins can be minimised by avoiding the use of the antiperistaltic agents.   The major risk factors that these medications have on Mr. Banks are bradycardia, breathing problem, allergy, dizziness and diarrhea. These side effects and the risk factors will delay the healing process. This drug induced reactions are of much important and should be taken care immediately as it is diagnosed. b) Drug induced bradycardia is a most important and common problem faced by the patients. The management of this condition depends on the severity of the patient and  nature of the symptom (Park et al., 2013). A disbalance in the electrolyte, beta-blockers and antiarrhythmic drugs are the major cause of the drug induced bradycardia. The attending nurse should immediately inform the anesthesiologist and the block level was monitored. The attending nurse should also allow the patient to relax and he was injected with intravenous glycopyrrolate to control the situation. The sound of the heart as well as the restlessness, dizziness and the confusion should also be observed and monitored thoroughly. The cause of the bradycardia must be identified properly and administration of the electrolyte may be an effective method to control this drug induced bradycardia (Truong et al., 2014). An adequate amount of fluid and slat should be given to the patient in order to overcome the condition. The precipitating factors are identified and avoided. The required measures should be taken while making the patient to lie down and elevating his legs. The patient should also be administered with theophylline if the patient exhibit mild symptoms such as fatigue or exertional dizziness. The patient should be made to lie down, the cardiac rhythm is monitored and provide oxygen if the nurse observe the chest pain of the patient. One of the most important medical emergencies that require an immediate attention and recognition from the attending nurse and the physician is the anaphylaxis. They require immediate intervention which includes high-flow oxygen, monitoring of the cause and the severity and the administration of the intravenous injections if needed. Allergy is another problem that is caused as a result of the usage of certain medication. Drug allergies may cause by the administration of any drug and produce serious side effects on the patients (Demoly et al, 2014). It may be fatal causing severe allergic reactions like swelling under the skin, asthma and may even lead to death of the patient. The nurses first need to identify the early signs and the symptoms exhibited by the patients who are under the medication that can cause allergic reactions to him. The nurses must have the knowledge of the various interventions that are required to protect the patient from any further harm (Demoly et al., 2014). The nurses may ask the physician to lower the dose of the drug which may help in reducing the allergic reactions. The nurses may also ask to provide desensitization to the patient that also proves to be effective in the reduction of the allergic reactions. Administration of epinephrine may be of much help in the adverse condition as this helps in the maintaining the blood pressure and antagonizes the effects of the mediators that are released. The delay in the administration of the epinephrine may sometimes lead to the death of the patient and the dose that is administered initially can be continued based on the patient’s response. 2. a) Surgical site infections occur due to bacteria, which gets inside the human body through surgical sites after an operation. The protective treatment methods adopted against a disease is called prophylaxis. The surgical site infections are life threatening and can also occur following implantations. They contribute to extra 400,000 days of hospitalization and the costs reach around US$ 10 billion per year. These infection risks are decreased by application of prophylactic antibiotics. In case of operations that last less than four hours one dose of antibiotic dose is generally sufficient. Prolonged surgeries require maintenance of proper antibiotic doses, such as the surgery administered to Mr. Banks. Surgical site infections can be prevented by regularly following medications. The extra cost of hospitalization gets reduced. Healthcare costs are lowered and no side effects are observed. (Hawn et al., 2013). Different pathogens that can cause infections in surgical wounds get destroyed by the antibiotics. These antibiotics have pharmacokinetic properties that utilize antimicrobial actions and destroy the bacteria that invade wounds (Y?lmaz & Özcengiz, 2016). The pharmacodynamics of these antibiotics involves the association between the antimicrobial effect and the concentration or dose of the antibiotics. Intravenous (IV) and oral (PO) routes are most commonly used to give these drugs. Mr. Banks got intravenous administration of Timentine. This administration involves fast bolus infusion rates to prolonged slow infusion rates (Lloyd et al., 2014). This increases bioavailability of the drug and completes the delivery of the drug inside the body. A peak in plasma level is observed. The type of infusion, dosage of drug and size of drug affects this peak. Therefore, patients suffering from severe forms of surgical site infection are prescribed this method of drug administration. If the drugs are timely administered and given in correct doses, contamination form surgical wounds can be avoided in the patient (Davis, 2014).   b) The first and foremost role of the nurse is to answer the needs and demands coming from their patient, the members of the family and the community sector. In order to provide quality care to their patients they incorporate potential and effective services (Esperat et al., 2012). Any failure in the provisions of effective and quality care can inculcate nosocomial infections (NI) which can infect the patients during their hospital stay. Apart from this issue any kind of improper management in their duties can lead to antimicrobial resistance (AMR). AMR is reported as one of the serious health issue in most of the countries (World Health Organization, 2012). It can exert serious impacts upon the patients affected along with their family and the hospital with health personnel. It is the duty of the nurse to perform sensitivity test in order to analyze the effectiveness of an antibiotic administered (Huss, Schiller & Schmidt, 2013). As the antibiotics have side effects like other medications, need for improving the antibiotic use is a major issue for patients’ safety.  Wherever required, they should always try to prescribe antibiotics with narrowed spectrum and prefer administering medicines orally rather than intravenous injections. Along with that, they should also develop a thorough understanding of the mechanism of the prescribed antibiotics (Peters, 2013).  They should be knowledgeable about the reasons for selecting the antibiotic. The registered nurse should always monitor the administration of the antibiotics.  However, it is also mandatory for the nurse to make the prescriber or the physicians aware of the medical history of the patient along with other associated factors that could influence the choice. Patients are often prone to build up a series of adverse reactions of drugs such as nephrotoxicity (Loghman-Adham et al., 2012). Patients with long exposure to antibiotics are at more risk towards the adverse effects of antibacterial drug action and indiscriminately alter the bacterial population of the patient (Soares et al., 2012).  The nurse should be aware about the medical conditions that can influence the immune system of the patients (Enck et al., 2013). Thus by understanding the antibiotic route of breakdown and having a profound knowledge about the essential side effects, the nurse will assist with better performance during implementing quality care to the patient (Boltz et al., 2016). In order to obtain microbial cultures and analyze their results, the nurse should be proficient in microbiology and well trained.  And finally, the nurse should be more aware about the history of allergies especially about penicillin. The ultimate aim of the nursing profession is to provide education to the patients related to exact antibiotic allergies and also their prognosis (Drews, 2013). Reference Boltz, M., Capezuti, E., Fulmer, T. T., & Zwicker, D. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice. Springer Publishing Company. Choi, J. B., Shim, Y. H., Lee, Y. W., Lee, J. S., Choi, J. R., & Chang, C. H. (2014). Incidence and risk factors of postoperative nausea and vomiting in patients with fentanyl-based intravenous patient-controlled analgesia and single antiemetic prophylaxis. Yonsei medical journal, 55(5), 1430-1435. Davis, J. (2014). Quality use of medicines. Australian Nursing and Midwifery Journal, 21(8), 26. Demoly, P., Adkinson, N. F., Brockow, K., Castells, M., Chiriac, A. M., Greenberger, P. A., … & Sanchez?Borges, M. (2014). International consensus on drug allergy. Allergy, 69(4), 420-437. Demoly, P., Adkinson, N. F., Brockow, K., Castells, M., Chiriac, A. M., Greenberger, P. A., … & Sanchez?Borges, M. (2014). International consensus on drug allergy. Allergy, 69(4), 420-437   Drews, F. A. (2013). Human factors in critical care medical environments. Reviews of human factors and ergonomics, 8(1), 103-148. Enck, P., Bingel, U., Schedlowski, M., & Rief, W. (2013). The placebo response in medicine: minimize, maximize or personalize?. Nature reviews. Drug discovery, 12(3), 191. Esperat, M. C. R., Hanson?Turton, T., Richardson, M., Tyree Debisette, A., & Rupinta, C. (2012). Nurse?managed health centers: Safety?net care through advanced nursing practice. Journal of the American Association of Nurse Practitioners, 24(1), 24-31. Hawn, M. T., Richman, J. S., Vick, C. C., Deierhoi, R. J., Graham, L. A., Henderson, W. G., & Itani, K. M. (2013). Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA surgery, 148(7), 649-657. Huss, N., Schiller, S., & Schmidt, M. (2013). Areas of Nursing within the Multidisciplinary Team and General Nursing Practice. In Fachenglisch für Pflege und Pflegewissenschaft (pp. 43-77). Springer Berlin Heidelberg. Lloyd, C. B. A., Weintrob, A. C., Hinkle, M. M. K., Fortuna, L. C. G. R., Murray, C. C. K., Bradley, W., … & Lloyd, G. (2014). Adherence to published antimicrobial prophylaxis guidelines for wounded service members in the ongoing conflicts in Southwest Asia. Military medicine, 179(3), 324. Loghman-Adham, D. M., Kiu Weber, D. C. I., Ciorciaro, D. C., Mann, D. J., & Meier, D. M. (2012). Detection and management of nephrotoxicity during drug development. Expert opinion on drug safety, 11(4), 581-596. Park, M. J., Lee, K. R., Shin, D. S., Chun, H. S., Kim, C. H., Ahn, S. H., & Bae, M. A. (2013). Predicted drug-induced bradycardia related cardio toxicity using a zebrafish in vivo model is highly correlated with results from in vitro tests. Toxicology letters, 216(1), 9-15. Peters, J. (2013). Nursing patients with skin disorders. Alexander’s Nursing Practice4: Alexander’s Nursing Practice, 397. Soares, G. M. S., Figueiredo, L. C., Faveri, M., Cortelli, S. C., Duarte, P. M., & Feres, M. (2012). Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs. Journal of applied oral science, 20(3), 295-309. Tosti, R., Trionfo, A., Gaughan, J., & Ilyas, A. M. (2015). Risk Factors Associated With Clindamycin-Resistant, Methicillin-Resistant Staphylococcus aureus in Hand Abscesses. The Journal of hand surgery, 40(4), 673-676. Truong, J., Yan, A. T., Cramarossa, G., & Chan, K. K. (2014). Chemotherapy-induced cardiotoxicity: detection, prevention, and management. Canadian Journal of Cardiology, 30(8), 869-878. World Health Organization. (2012). Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae. Y?lmaz, Ç., & Özcengiz, G. (2016). Antibiotics: Pharmacokinetics, toxicity, resistance and multidrug efflux pumps. Biochemical pharmacology.

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