Paper Instructions: Read a selection of your colleaguesâ€™ responses and respond to two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure. Provide 2 references for each colleague’s response.
Factors in the Effectiveness of Medication
The patient in this discussion is a middle-aged male who was recently diagnosed with metastatic cancer, with a primary tumor in the colon. The patient was referred to hospice due to the wide-spread nature of the cancer. He also had a complex history of opioid addiction, which he had successfully been treated with suboxone, counseling, and spiritual care. Due to the pain from the large tumor, he was restarted on opioids. He began to have issues with keeping medications down to assist with his pain. He discussed his addiction with the physician and since his diagnosis, he had taken up to 20 Percocet daily for pain, which was much more than his primary care provider had prescribed.
The challenges of this case were many. First and foremost, the patient was overtaking medications that lead to worsening liver function. He was taken off Percocet and placed on oxycodone for pain. Soon, it became clear that his intestinal absorption was also a factor in his case. He called in a pain crisis on the second day after admission, but by that night, his family called in a panic as he was almost comatose. The kinetics of the medication were affected by his large, basketball-sized tumor that blocked not only his colon but many areas within the intestinal tract, compressing the duodenum and stomach. Also affecting the absorption, was his previous opioid overuse and tolerance to opioids.
Personalized Plan of Care
Several considerations are to be considered with this patient. At the forefront of care, should be the consideration that the patient is in a painful terminal process. Supporting the patient, and research about terminal care for patients with previous addiction is imperative to start the plan of care. Social work, nursing, physician, and spiritual support can help with adherence to a regimen and with intrusive maladaptive behaviors during care for these types of patients. (Polansky, 2020). As the APRN, I would also explore the absorption of medications considering the size and location of the tumors that the patient had. Since the patient had nausea and intestinal absorption issues, alternative medications, and routes, such as a fentanyl patch should be explored. To safely transition to fentanyl from pills, considerations of the patientsâ€™ layer of subcutaneous fat, and previous opioid use for dosing is appropriate (Oosten, 2016).
Medication Management for an Elderly Dementia Resident
The chosen resident at the skilled nursing home is an 87-year-old female with diagnoses of dementia, mood affective disorder, anxiety, depression, and dementia. Her behaviors include pacing, wandering, crying episodes, insomnia, anorexia, and occasional combativeness. She has had several falls within the last ninety days. The use of benzodiazepines in the elderly population has been associated with increased falls (Kormelinck et al., 2019). Due to her constant movement and inability to sit for a meal, this resident is losing weight and is often slightly dehydrated. This dangerous loss of bodily fluids can cause impaired perfusion and dizziness, which can also contribute to her history of falls (Hamrick et al., 2020).
Her current PO medications include Seroquel, Lorazepam, Memantine, PRN Haldol, and topical ABH (Ativan/Benadryl/Haldol) gel. Her behaviors appear cyclical as she is highly active for 2-3 days, then has a day of complete rest and repeats this cycle. Antipsychotics have been linked to increases in CVAs and death in the elderly population (Kormelinck et al., 2019). Her medication is being managed by her primary care physician, and she has been seen by a psych provider only once in the past 180 days.
Recent labs show a decline in kidney and liver functioning. Antipsychotics and Benzodiazepines are absorbed in the GI system, metabolized in the liver, and excreted through urine and feces (Rosenthal & Burchum, 2021). As renal functions decline, these medications may accumulate in the patientâ€™s system (Rosenthal & Burchum, 2021). These medications elicit a response of decreased and slowed behaviors. This action effectively causes the patient to be stable enough to sleep and eat while also improving social interactions. Consequently, there are no FDA approved antipsychotics for dementia patients with behaviors (Rose & Kass, 2019).
My plan of care for this resident would include medication management from a trained psych provider. Also, this resident would be transferred to an appropriate facility with patients who have similar diagnoses and behaviors. With trained staff who specialize in caring for dementia patients, the most effective behavior modifications can be implemented. The psych provider will continue regular medication reviews and appropriate laboratory monitoring.