NURS 6521 COMPLETE WEEK DISCUSSIONS PACKAGE

• Think about a personalized plan of care based on these influencing factors and patient history in your case study. Case Scenario Mrs. Perez is a 65-year-old Hispanic female who weighs 200 lbs. and is 5’5. She has a medical history of severe left knee arthritis, hypertension, anxiety, and early stages of congestive heart failure. Mrs. Perez follows a regular diet, does not smoke, drink, or do any illicit drugs. She had a scheduled left total knee replacement, which was a success. Mrs. Perez was then sent to a rehabilitation facility for further physical therapy. While in rehabilitation, Mrs. Perez’s incision became infected and was sent back to our facility for evaluation and treatment. The patient was first sent to the operating room for an incision and drainage where a wound culture was obtained; the wound was left semi-opened (required deep daily wound care) and infectious disease was consulted to aid in the case. Wound culture came back positive for MRSA and was placed in Vancomycin. Regular vancomycin trough levels were checked and even with being careful with its monitoring, Mrs. Perez developed renal failure and had to be placed on hemodialysis. Pharmacokinetics and Pharmacodynamics The treatment used: Vancomycin (glycopeptide antibiotic): indicated for severe bacterial infections. Pharmacokinetics of vancomycin: • Dosage recommended: 15-20 mg/kg IV every8-12 hours. Renal function needs to be known: Creatinine clearance 50-90: 15mg/kg x 1, then usual dose every 12-24 hours; CrCl 10- 50: 15 mg/kg x 1, then usual dose every 24-96 hours; CrCL 10: 15 mg/kg x1, then usual dose every 4 – 7 days • Common reactions: red-man syndrome, hypotension, fever, nausea, rash, urticaria, BUN, and creatinine elevation • Adverse reactions: anaphylaxis reaction, thrombophlebitis, tissue necrosis, vasculitis, nephrotoxic, ototoxic • Monitoring parameters: BUN, creatinine at baseline, then periodically; WBC, serum drug levels • Pharmacology: metabolism (none), excretion via the urine if via IV route or feces via PO route. Half-life between 4-6 hours, mechanism of action: bactericidal; inhibits cell wall and RNA synthesis (Epocrates, 2017) According to Waineo, Kuhn, & Brown (2015), vancomycin does not need a high peak concentration in order to be effective. Trough levels are used routinely to make sure there are therapeutic efficacy and safety. Vanco trough levels are also used to adjust doses as needed. Waineo, Kuhn, & Brown (2015) continue to explain that the timing of a trough collection and measurement is very important. Vancomycin concentration needs to be measured within 30 minutes of the next dose. If collected more than 30 minutes from next dose, it will provide a deceptively greater value. This same article mentions that inaccurate blood collection is the main cause of misleading vancomycin levels. In the case of Mrs. Perez, trough levels were in fact done (on time? late?), but she still developed renal failure which led her to be placed in hemodialysis. This could have been an influencing factor that led to Mrs. Perez hemodialysis treatment. Pharmacodynamics of vancomycin: it can be affected by the patients' age, medical history (specific disorders), or by other medications being taken. Mrs. Perez is 65 years old, weighs 200 pounds and has hypertension and early stages of CHF. This last one, in particular, could have been a factor that affected vancomycin clearance and contributed to her to renal