Medication Regimen of Jolene Essay
Task 3 Case study
Jolene is now 35 and still living in Dalby with Jack. The farm is not doing so well due to the drought. Jolene has had to help on the farm for the past 2 years. About 18-months ago she had a motorbike accident that resulted in a compound fractured tibia and fibula and a blunt force head trauma.
The fractures were surgically repaired with pins and plates. Jolene has recovered from the orthopaedic surgery and is now fully mobile but does experience leg pain and surgical site discomfort at times.
About 3-months after the surgery Jolene returned to the emergency department with extreme chest pain and dyspnoea. During that admission she was diagnosed with a pulmonary embolus and DVT. She remains on anticoagulant medication.
About 12-months ago Jack found Jolene disorientated on the veranda. He called the ambulance. While being transported to the emergency department Jolene had a tonic-clonic seizure lasting 3-minutes. The physician at the hospital diagnosed traumatic epilepsy related to the motorbike accident and prescribed medication to treat the condition.
Now Jolene is at the GP clinic for a follow-up appointment. Her protracted recovery has contributed to her feeling depressed. The GP had previously prescribed medication and other therapies for the depression. However, today’s visit from Jolene is because she believes she is pregnant. The GP has estimated that Jolene is in the first trimester of confinement.You are the clinic nurse/midwife.
Review the medication regimen of Jolene.
Write an academic essay that includes discussion of the following points.
1. Application of pathophysiological concepts
2. Application of pharmacokinetics and pharmacodynamics to explain how medications work and interact with the human body.
3. Relate the drug mechanism of action to main side-effects of the drug and, discuss benefits, risks and management of adverse reactions using person-centred approaches.
4. Evidence-based argument and justification of decisions, coherent written expression and presentation
Referencing style conforms to Harvard referencing style used at USC
Medication Regimen of Jolene
Jolene has visited the GP clinic for her follow-up appointment and consultation as she believes she could be pregnant. The GP estimates that the patient is in her first trimester of confinement. Jolene is 35 and still living with Jack in Dalby. Around 18-months ago, she had an accident that led to the compound fractured tibia, fibula, and blunt force head trauma. She recovered from her orthopedic surgery and is fully mobile, though she still experiences leg pain and surgical site discomfort some times. Since then, the GP had prescribed medication and other therapies for depression, pulmonary embolus, DVT, and traumatic epilepsy.
Jolene’s history and physical examination will play an important role in pregnancy diagnosis and treatment regimen. Since this is a follow-up appointment, there is a need to inquire whether the patient is still experiencing leg pain and surgical site discomfort from her orthopedic surgery. Jolene was also diagnosed with pulmonary embolus and DVT and had been taking the anticoagulant medication. First, the challenge in dealing with PE is that the patient rarely displays the classic clinical presentation of PE, the sudden onset of pleuritic chest pain, hypoxia, and shortness of breath (Chang & Daly 2020). Though, the majority of patients with PE have no apparent symptoms at clinical presentation. Thus, there is a need to assess whether the patient has symptoms varying from abrupt catastrophic hemodynamic collapse to progressive dyspnea. Studies of patients who have died suddenly from pulmonary embolus have revealed that the individuals have complained of distressing symptoms for weeks before death.The clinical presentation of deep vein thrombosis differs from the location and extent of a thrombus. The DVT’s basic signs and symptoms comprise warmth, asymmetrical swelling, or pain in extremity, and high suspicion index should be manifested in patients with risk factors such as advancing age, cancer, oral contraceptives, and obesity (Daly et al. 2017). In the original form, the patients are stratified into three classes, low, intermediate, or high risk, based on the absence or absence of nine clinical criteria. Furthermore, the patient was diagnosed with traumatic epilepsy connected to the motorbike accident and had been taking medication to treat the condition. Post-traumatic seizures could be present anywhere in the spectrum, comprising partial seizures with no consciousness adjustment, partial seizures with alteration of consciousness, and symptomatic and generalized seizures (secondary). The most common site for the late post-traumatic seizures is the temporal lobes linked with an aura about two-thirds of the time (Craft & Gordon 2019). These auras can be autonomic, psychic, olfactory, and gustatory hallucinations. Following the evolution of the seizure, the consciousness alteration can occur, and patients might stare and be unresponsive and exhibit stereotyped behaviours, as well as automatisms.
Her extended recovery has contributed to her depression; hence, Jolene has been taking medication and other therapies as part of the depression treatment plan. The patients with significant post-operative depressive order might not firstly present with complaints of anhedonia, low mood, and other typical symptoms. The presenting complaints can be somatic fatigue, excessive sleeping, weight change, headache, loss of appetite, and abdominal distress. Also, the patient could complain more about being irritable, having difficulty concentrating, and losing interest in activities rather than low mood or sadness. Now Jolene is at the GP clinic for a follow-up appointment, and she could be on her first trimester of confinement. Clinical signs and symptoms are the earliest pregnancy indication and should be considered in the initial patient evaluation. They include amenorrhea, nausea, abdominal enlargement, vomiting, fetal movements, breast tenderness, and urinary complaints. But, the physical symptoms are not adequately reliable to diagnose early pregnancy. Positive pregnancy signs include the detection of the fetal heartbeat, fetal movement, maternal perception, and ultrasonography pregnancy demonstration.
Jolene’s Medications and Mechanism of Action
Jolene was currently taking anticoagulant medication following her pulmonary embolus and DVT diagnosis fifteen months ago. She is also taking prescribed medication to treat traumatic epilepsy and post-operative depression. The pharmacokinetics and pharmacodynamics describe the amount of drugs in one’s body at any given time and pharmacologic effects caused by a drug, resulting in clinical response, respectively (Bullock & Manias 2016). The understanding of pharmacokinetics and pharmacodynamics will aid in enhancing the ability to make well-informed choices in the treatment.
Anticoagulant Medication- Warfarin
The mechanism of action is that the medication blocks the carboxylation of some glutamate residues in prothrombin and factors VII, IX, and X plus endogenous anticoagulant proteins S and C. The blockade leads to incomplete molecules, which are biologically inactive during coagulation. This protein carboxylation is physiologically combined with vitamin K oxidative deactivation (Jackson et al. 2014). The medication precludes the reductive metabolism of inactive forms of vitamin K back to their active form by epoxide reductase. The mutational change of the enzyme leads to genetic resistance in a subgroup of the human population. The medication indications are prophylaxis and treatment of venous thrombosis and extension pulmonary embolism as well as prophylaxis and treatment of thromboembolic complications linked to the cardiac valve replacement and atrial fibrillation.
The pharmacokinetics are 100% bioavailability, 99% is bound to the plasma albumin, resultant in the small apparent distribution volume (albumin space), and the half-life is 36 hours. There exists an eight to12 hour delay in the action owing to the time taken for degradation of the clotting factors in the circulation. There are substantial interactions with disease states and other drugs, which could be subdivided into pharmacodynamic and pharmacokinetic interactions. First, the pharmacokinetic interactions could arise from enzyme induction, reduced binding of plasma protein, and enzyme inhibition. Secondly, the pharmacodynamic mechanisms for drug interactions are synergism, competitive antagonism, as well as the altered physiologic vitamin K control loop. The serious interactions are ones that can increase the anticoagulant effect and risks of bleeding. Some of the drugs that increase the prothrombin time through pharmacokinetic interactions comprise amiodarone, cimetidine, among other drugs. Besides, barbiturates and rifampin produce a distinct decrease in the anticoagulant effects through the induction of the cytochrome P450 enzymes, which can metabolize the medication.
The antiepileptic drugs are given to preclude further seizures and can completely eradicate seizures for around 35 per cent of patients with PTE. Though, antiepileptic drugs prevent seizures only when taken as they cannot lessen the occurrence after a patient stops the medication (Koutoukidis et al. 2017). Antiepileptic carbamazepine is one of the most common medications used in treating PTE. The pharmacodynamics or indications of the drug are used in the management of partial seizures and tonic-clonic seizures together with the trigeminal neuralgia symptoms by inhibiting the sodium channels. The drug’s mechanism of action is blocking the Na+ channels by binding preferentially to voltage-gated sodium channels in inactive conformation that prevent sustained and repetitive firing of the action potential. The drug affects the serotonin systems; however, the relevance to the effects of antiseizure is still uncertain. There exists empirical evidence that carbamazepine is a serotonin releasing agent and perhaps a serotonin reuptake inhibitor.
The pharmacokinetics include carbamazepine is fairly slow, but it is well absorbed upon oral administration, and oral clearance is 25 ± 5 mL/min after one dose and 80 ± 30 mL/min after some doses. The bioavailability is within the range of 75 to 85% of the ingested dose and 75%-80% binding to plasma proteins. Carbamazepine induces its metabolism, which enhances clearance, reduces half-life, and lowers the serum levels. The drug is metabolized in the liver, where CYP3A4 metabolizes carbamazepine into an active metabolite, carbamazepine-10 11- epoxide that is further metabolized to trans-diol form by epoxide hydrolase enzyme. There are added hepatic cytochrome enzymes, which contribute to the metabolism of CYP2C8, CYP2B6, and CYP3A5. The plasma half-life is approximately 30 hours when given as a single dosage due to hepatic metabolism (CYP 3A4) of active metabolites. However, it is an inducer of hepatic enzymes (CYP 3A4, 1 A2, 2B6, and 2C9/19); thus, its plasma half-life is shortened to around 15 hours when ingested repeatedly. The volume of distribution ranges from 0.70 to 1.4 L/kg. The drug crosses the placenta and blood-brain barrier, but higher concentrations are found in the kidney and liver—the route of elimination 72% in urine and remainder in faeces.
During the follow-up visit, the GP will monitor the lung and neurological function to assess the efficacy as well as the side effects of Jolene’s antiepileptic and anticoagulant medications. In addition, since the patient is in her first trimester of confinement, there is a need to adjust her current treatment regimen. The goal is to offer safe and effective delivery of quality health services, which promote the health and well-being of the patient’s pregnancy, birth, and postnatal period as well as a smooth transition into parenting (Nagle et al. 2017). The midwifery and nursing standards for practice encompass the responsibility and accountability for maintaining the capability of women’s health support, healthcare, and advice from conception to the postnatal period (Cusack 2019). Besides, the standards of practice also necessitate the promotion of normal physiological childbirth, the identification of complications for the pregnant woman and baby, and consultations with referrals to care or other suitable assistance.
Both maternal and fetal concerns should be taken into consideration at all times, with careful evaluation of both risks and benefits of anticoagulant therapy for the patient. The prescription of anticoagulants to pregnant women can be hard and stressful due to increased risks of clots. Pregnancy is one of the primary risk factors for the development of blood clots due to the natural biological response aimed at protecting women against the potential major bleeding associated with miscarriages and childbirth. Also, oral anticoagulants or blood thinners, like warfarin, are not safe for the unborn baby (Mckenzie & Porter 2015). The drugs’ hemorrhagic complications present can consist of paresthesia, paralysis, headache, joint, muscle, chest, abdomen or any other pain, difficulty in swallowing and breathing, dizziness, shortness of breath, weakness, unexplained swellings, and unexplained shock (Moini 2012). The contraindications of the anticoagulant medication are FDA pregnancy category X as it can cause miscarriage, fatal bleeding, stillbirth, and congenital disabilities in the unborn baby. The side effects include non-fatal or fatal bleeding from tissue and organ and the necrosis of skin and other tissues.
Due to the risks of the oral anticoagulant medication, the GP should recommend switching to either low-molecular-weight heparins and unfractionated heparin as they are quite safe for the patient and the baby (Schaefer et al. 2011). The proposed drug is efficient when correctly selected, the right dosage is administered, and monitored throughout the pregnancy until at least six weeks post-delivery. The use of blood-thinning medications that are injected underneath the skin, like unfractionated and standard heparin and low-molecular-weight heparin, has numerous benefits to the patient and the unborn baby. They cannot cross the placenta or enter the unborn baby’s bloodstream; hence, they are safe for use throughout pregnancy, childbirth, and breastfeeding. In Jolene’s case, LMWH is preferred drug over the heparin as it presents minimal side effects and has no congenital disabilities and bleeding problems for the unborn baby. LMWH binds to the serine protease inhibitor (anti-thrombin) and then forms the conformational change that accelerates the reticence of activated factor X in prothrombin conversion to thrombin. Hence, the thrombin cannot transform fibrinogen into fibrin strands and lead to the formation of clots.Antiepileptic Drugs
The safety of antiepileptic medication in pregnancy should involve the pregnant woman, fetus while in the womb, and succeeding extra-uterine existence as both neonate and infant. The overall safety of antiepileptic drugs in pregnancy does not considerably differ from the safety of these medications in women generally (Eadie 2019). The exception is effects of pregnancy can affect their handling and effects on the fetus. The pregnancy could be imperilled by loss of seizure control occasioned by an increase in antiepileptic drug clearances that not compensated for by suitable adjustments of medicine dosages. Seizures in pregnancy can lead to slowing the fetal heart rate, reduced oxygen to the fetus, fetal injury, preterm labour, and premature birth (Bryant & Knights 2015). Intrauterine exposure to some antiepileptic drugs can be linked to the development of structural fetus malformations and postnatal neurodevelopmental delay, low IQ values, and autism. But, it is best to continue taking the carbamazepine -antiepileptic medication in pregnancy to remain seizure-free. The drug carbamazepine is generally perceived as one safest antiepileptic agent during pregnancy. In all antiepileptic cases, the patients can be reassured that there are low chances of abnormality. However, it is essential that the patient also takes folic acid prophylaxis during the first trimester of confinement. The dosage of folic 5mg PO/day can be suitable for the patient who has been receiving established antiepileptic therapy.
Jolene’s new medication regiment will include low-molecular-weight heparins that lower the risks of blood clots during pregnancy and after childbirth. LMWH is the preferred anticoagulant as it presents fewer side effects than heparin. Besides, the carbamazepine and folic acid will be included in Jolene’s regimen to minimize the risks for the patient and baby. These are the safest antiepileptic medication that is effective for the eradication of seizures and subsequent risks. The newly prescribed medication will aid the treatment of pulmonary embolus, DVT, and traumatic epilepsy. Thus, the new drug regimen is safe for use and efficient safe for use throughout pregnancy, childbirth, and breastfeeding stages.
Bryant, B. J., & Knights, K. M. (2015). Pharmacology for health professionals. Chatswood, N.S.W: Elsevier, Australia.
Bullock, S., & Manias, E. (2016). Fundamentals of Pharmacology. Melbourne, Victoria: Pearson, Australia.
Chang, E., & Daly, J. (2020). Transitions in nursing: preparing for professional practice. Chatswood, NSW: Elsevier, Australia.
Craft, J., & Gordon, C. (2019). Understanding pathophysiology. Chatswood, NSW: Elsevier.
Eadie M.J. (2016). Antiepileptic drug safety in pregnancy: Possible dangers for the pregnant woman and her foetus. Clinical Pharmacist.
Cusack, L. (2019). New Midwife Standards For Practice- Nursing and Midwifery Board of Australia. Get to know your new standards for practice before 1 October. Australian Midwifery News. 18, 10.
Daly, J., Speedy, S., & Jackson, D. (2017). Contexts of nursing: an introduction. Chatswood, NSW: Elsevier.
Jackson, L. R., & Becker, R. C. (2014). Novel oral anticoagulants: pharmacology, coagulation measures, and considerations for reversal. Journal of Thrombosis and Thrombolysis: A Journal for Translation, Application, and Therapeutics in Thrombosis and Vascular Science. 37, 380-391.
Koutoukidis, G., Stainton, K., & Hughson, J. (2017). Tabbner’s nursing care: theory and practice. Chatswood, N.S.W: Elsevier.
Mckenzie, G., & Porter, T. (2015). Clinical companion: medical-surgical nursing. Chatswood, N.S.W: Elsevier, Australia.
McKenna, L & Lim, A.G (2019). McKenna’s Pharmacology for Nursing and Health Professionals: Australia and New Zealand. Macquarie Park, NSW: Wolters Kluwer.
Moini, J. (2012). Comprehensive exam review for the pharmacy technician. Australia, Delmar Cengage Learning.
Nagle, C., Heartfield, M., McDonald, S., Morrow, J., Kruger, G., Bryce, J., Birks, M., Cramer, R., Stelfox, S., & Hartney, N. (2017). A necessary practice parameter: Nursing and Midwifery Board of Australia Midwife standards for practice. Women and Birth. 30, 10-11.
Schaefer, C., Peters, P. W., & Miller, R. K. (2011). Drugs during Pregnancy and Lactation: Treatment Options and Risk Assessment. Oxford Elsevier Science.