Answer

Task 2 Case Study

Response to Question 1

            The national standard medication chart safety features have been embedded in the patient’s chart. The first safety feature is the checking of any previous drug allergies and/or adverse react and any contraindication prior of administration (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2014). There are no known drug allergies or adverse drug reactions in the provided patient chart. If there is any known drug allergies or previous histories, nursing staff and medical practitioners should document the drug or substance, the adverse reactions, and the type of observed anaphylaxis (ACSQHC, 2014). Drug hypersensitivity reactions are the most common reasons of consultations in allergy departments. Adverse drug reactions can increase cost of care associated with increased length of hospitalization and management of hypersensitivity reactions. It may also worsen clinical outcomes (Al-Ahmad et al., 2020). Medication-related adverse events can negatively impact on the patient’s quality of life and increase burden of care (Huang & Khalil, 2020).

            The second safety feature is documentation of nurse-initiated medicines in the patient chart (ACSQHC, 2014). In the provided chart, labetalol IV 20mg stat is prescribed as a nurse-initiated medicine the patient (Rodriguez). Registered nurses (RNs) are expected to apply their clinical judgement so as to initiate administration of over-the-counter medications within their territory or state legislative requirements. Besides, RNs should adhere with registered nursing professional guidelines and organizational guidelines when prescribing medications. Protocols requires nurses to provided the dosage, indication for each drug, allergies, contraindications, and adverse drug reactions associated with the nurse-initiated medications (ACSQHC, 2014). Consistently, labetalol hydrochloride is an over-the-counter medication indicated for management of hypertension. It is used in management of all grades of hypertension. Side effects include dizziness, headache, light-headedness, depressed mood, blurred vision, muscle cramps, tiredness, upset stomach, swelling of the ankles, vomiting, tremor, blocked nose, problem with sexual function, and increased sweating (NPS Medicine Wise, 2020).

            The last observed safety feature is that the patient’s details have been clearly documented on each page the National Residential Medication Chart. The details must include the patient’s preferred name, URN/MRN, full name as it appears in the Medicare card, individual health identifier, and a recent photograph (ACSQHC, 2014). The above information is often completed at the point of admission by the admitting RN. In other cases, the details can be completed by a medical practitioner (ACSQHC, 2014). Accurate documentation and repeating of patient’s details on each page of the medication chart helps to reduce the risk of medication errors. For example, it can prevent administration of prescribed medications to the wrong patient (Rodziewicz, Houseman, & Hipskind, 2021). Standard 6 of the Nursing and Midwifery Board of Australia (2016), requires RNs to provide safe, responsive, and appropriate quality nursing practice. The practice of documenting patient details on each page helps to support realization of Standard 6.

Response to Question 2

Paracetamol

            Paracetamol 1g 4 hours PRN has been prescribed to Rodriguez to relieve of migraine headache. In adults (33 to 50kg) dosage is 15mm per kg at a schedule of 4 to 6 hourly as the need arises. In case of renal impairment (CrCl <30mL/min), the dosing interval should be increased to 6hourly (maximum 3g daily). Paracetamol can be taken with or without food. It is incompatible with diazepam, acyclovir Na, and chlorpromazine HCl (MIMS, 2021_a). Paracetamol should have not been prescribed since the patient has been prescribed diazepam. Besides, paracetamol is contraindicated for Rodriguez since she is 24 weeks pregnant (MIMS, 2021_a). It is contraindicated in case of hypersensitivity, active liver disease and/or severe hepatic impairment (MIMS, 2021_a). It is excreted in urine in unchanged form (<5%), glucuronide metabolites (60-80%), and as sulphate metabolites (20-30%). Elimination half-life is about 1 to 3 hours. Potentially fatal adverse reactions include acute tubular necrosis, hepatotoxicity, and hypersensitivity (MIMS, 2021_a).

Labetalol

            Labetalol 20mg IV stat is indicated for treatment of hypertension since Rodriguez has presented with high blood pressure (146/100 mmHg).  Labetalol competitively inhibits adrenergic stimulation of beta-receptors within the bronchial muscle, myocardium, and vascular smooth muscles and alpha-1 receptors within vascular smooth muscle.  Labetalol is listed as pregnancy category C drug (MIMS, 2021_b). Special precautions should be observed among the elderly, lactating mothers, and pregnant women (MIMS, 2021_b). A pregnancy category C medication may have severe effects on the fetus but potential benefits may outweigh potential risks in pregnant women (Drugs.com, 2021). Labetalol is used to control hypertension in pregnant women. In a randomized controlled trial labetalol reduced chronic hypertension in pregnant women to an average of 135/84mmHg (Webster et al., 2017). It should be taken with food or immediately after meals. The drug is incompatible with alkaline solutions and bicarbonate 5% solution. Contraindications for use of labetalol include obstructive airway disease, second- and third-degree heart block, prolonged or severe hypotension, cardiogenic shock, severe bradycardia, and heart failure (MIMS, 2021_b).

Nifedipine

            Nifedipine 10mg PO bd is indicated for management of Rodriguez’s hypertension (146/100mmHg). Nifedipine is a dihydropyridine calcium-channel blocker, which blocks entry of calcium ions through the select voltage-sensitive areas of the smooth muscle or slow channels as well as the myocardium during the depolarization phase resulting in coronary vasodilation and smooth muscle relaxation. It is contraindicated in case of cardiogenic shock, unstable angina, clinically significant aortic stenosis, acute angina attacks, within one month of experiencing myocardial infarction, and concomitant use with rifampicin (MIMS, 2021_c). It is a pregnancy category C drug; thus, may have adverse effects on the fetus but used when benefits outweigh the risks just like labetalol (Drugs.com, 2021). In pregnant women with chronic hypertension, nifedipine can achieve a target reduction of blood pressure to 134/85mmHg (Webster et al., 2017). Nifedipine is excreted via urine and feces. Its elimination half-life is about 2 to 5 hours (MIMS, 2021_c).

Diazepam

            Diazepam 2mg PO TDS is indicated for treatment of anxiety and agitation. Diazepam exerts anticonvulsant, anxiolytic, amnestic, muscle relaxant, and sedative effects (MIMS, 2021_d). Diazepam is a pregnancy category D drug (MIMS, 2021_d). In a category D drug, there is evidence of risks to the human fetus due to adverse reactions but may be used if potential benefit outweighs the risks (Drugs.com, 2021). It is contraindicated in chronic or acute severe respiratory insufficiency, myasthenia gravis, respiratory depression, severe hepatic insufficiency, sleep apnea, phobic or obsessional states, acute narrow-angle glaucoma, hyperkinesis, chronic psychosis, and acute porphyria (MIMS, 2021_d). it should be used with special precaution in pregnant and lactating women. Adverse reactions include withdrawal symptoms, paradoxical reactions, anterograde amnesia, drug dependence, habituation, constipation, diplopia, blurred vision, nausea, gastrointestinal disturbances, depression, confusion, and hypotension. It is metabolized in the liver and excreted in urine. Elimination half-life is about 44 to 48 hours (MIMS, 2021_d).

Response to Question 3

            One of the strategies for ensuring safe medication practice in this case is by following the five rights of medication administration. Five rights of medication administration include right dose, right patient, right route, right drug, and right time (Chu, 2021). There is need to adhere to the five rights of medication when administering paracetamol, labetalol, nifedipine, and diazepam. However, evidence indicates the urgency to withdraw use of paracetamol since it is incompatible with diazepam. Co-administration of paracetamol and diazepam at the same time can increase the risk of drug-drug interactions (MIMS, 2021_a).

            The other strategy is frequent checking (interval of 30 minutes) and monitoring of the patient’s vital signs. Of particular interest is Rodriguez’s current stage 2 hypertensive state (146/100mmHg) (CDC, 2020). Target blood pressure range associated with use labetalol is 135/84mmHg and that of nifedipine is 134/85 mmHg (Webster et al., 2017). Minoring of blood pressure is important since concomitant use of nifedipine and labetalol can increase the risk of hypotension, which may be life threatening (Webster et al., 2017). On the other, hand, it is important to determine whether concomitant use of labetalol and nifedipine has achieved significant impact in lowering of Rodriguez’s high blood pressure state.

            Patient education can also improve outcomes. The patient should be educated about potential side effects of each medication, dosage and dosing schedule, therapeutic effects, and the desired outcomes. The patient should also be taught to report adverse drug reactions for immediate or urgent action to be taken (Chu, 2021). Patient education is important since it can increase the patient’s level of engagement in her care, improved medication adherence, improved patient’s engagement in shared decision-making, higher levels of patient satisfaction, and better treatment outcomes. Patient education should be presented in simple language that can easily be understood by the patient (Timmers et al., 2020).

Response to Question 4

            Rodriguez, your blood pressure is you have been administered nifedipine to help in management of your hypertension. Your last recorded blood pressure reading is 146/100mgHg, which is considered as stage 2 hypertension according to the U.S. Centers for Disease Control and Prevention [CDC] (2020). In response you have been prescribed nifedipine to help reduce your blood pressure level to a target of about 134/85mmHg (Webster et al., 2017).   There are some few things you should know concerning the use of this medication. You should not operate machinery or drive after using nifedipine since in causes dizziness, lethargy, and transient blindness. As such, it may increase the risk of accidents, injury or even death. You may experience some adverse reactions such as peripheral edema, increased heart rate, syncope, constipation, abdominal pain, flatulence, headache, and/or coughing associated with the use of the drug (MIMS, 2021_c).