NSG 3370 WEEK 7 PART 2 DISCUSSION

NSG 3370 WEEK 7 PART 2 DISCUSSION Your patient is a 77-year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril and Atorvastatin. • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give? Hydrochlorothiazide: Diuretic, used to treat blood pressure, and treat fluid retention (edema). To make sure hydrochlorothiazide is safe for you, tell your doctor if you have: • kidney disease; • liver disease; • gout; • glaucoma; • low levels of potassium or sodium in your blood; • high levels of calcium in your blood; • a parathyroid gland disorder; • diabetes; or • an allergy to sulfa drugs or penicillin. Call your doctor at once if you have: • a light-headed feeling, like you might pass out; • eye pain, vision problems; • jaundice (yellowing of the skin or eyes); • pale skin, easy bruising, unusual bleeding (nose, mouth, vagina, or rectum); • shortness of breath, wheezing, cough with foamy mucus, chest pain; • signs of electrolyte imbalance--dry mouth, thirst, drowsiness, lack of energy, restlessness, muscle pain or weakness, fast heart rate, nausea and vomiting, little or no urine; or • severe skin reaction--fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling. Common hydrochlorothiazide side effects may include: • nausea, vomiting, loss of appetite; • diarrhea, constipation; • muscle spasm; or • dizziness, headache. Lisinopril: is an ACE inhibitor, used to treat high blood pressure and congestive heart failure. To make sure Lisinopril is safe for you, tell your doctor if you have: • kidney disease (or if you are on dialysis); • liver disease; • diabetes; or • high levels of potassium in your blood. If you have diabetes or kidney disease, you may not be able to take Lisinopril if you are also taking aliskiren (Tekturna, Tekamlo, Valturna, Amturnide Atorvastatin: Treats high cholesterol Patient should report if experiencing confusion, memory loss, and/ or developing diabetes (Edmunds & Mayhews, 2013). According to Edmunds and Mayhews (2013) new research suggests an increase of aggression with the use of any Statin medication, particularly in “woman and the elderly” (p. 300). Differential Dx: Altered Mental Status R/T dehydration and/or infection (UTI) Drug induced toxicity by Atorvastatin Depression (Late-onset) Altered mental status can be related to dehydration thus leading to infection such as urinary tract. The patient is taking hydrochlorothiazide which is used to treat high blood pressure and used as a diuretic to treat fluid retention (Edmunds & Mayhews, 2013). Clinical signs and symptoms of hydrochlorothiazide: light headed, dizziness, electrolyte imbalance, dry mouth, thirst, nausea, vomiting, diarrhea, constipation, and muscle spasms (Edmunds & Mayhews, 2013). Clinical symptoms of dehydration can result in thirst, dry mouth, little to no urine, increase bacteria growth, infection, and impair cognitive state of mind (Benton & Young, 2015). According to Benton and Young (2015) as “dehydration reduces body mass more than 2%, [there are] consistent reports that mood is influenced, fatigue is greater, and alertness is lower” (p. 95). This patient’s AMS maybe affected from an infection such as urinary tract infection (UTI) due to dehydration. According to Forsey (2012) it is common in elderly patients to be prone to UTI due to dehydration alters the immune response within the body. UTI is one of the common causes of bacteremia in the elderly. Typical signs of behaviors demonstrated may be increased confusion, agitation, hallucinations, increased aggression, falls, and poor motor skills and dizziness (Forsey, 2012). Patients who experience any type of infection won’t have signs of pain or fever; they exhibit more cognitive changes, perhaps delirium. Drug induced toxicity by Atorvastatin Atorvastatin is a medication used to lower cholesterol levels by lowering low-density lipoprotein (LDL) and raising high-density lipoprotein (HDL). Signs and symptoms of this medication include: memory loss, fatigue, confusion, aggression, weakness, tiredness, loss of appetite, muscle spasms, and urinary tract infection (Edmunds & Mayhews, 2013). According to Edmunds and Mayhews (2013) new research suggests an increase of aggression with the use of any Statin medication, particularly in “woman and the elderly” (p. 300). Patient should report if experiencing confusion, memory loss, and/ or developing diabetes (Edmunds & Mayhews, 2013). Depression According to Taylor (2014) late-life depression occurs in adults greater than 60-years of age and exhibits as a major depressive disorder among the elderly. Patients are more likely to have neurologic abnormalities and risk for subsequent dementia with late-onset of depression (Taylor, 2014). This patient is possibly depressed due to coexisting medical illness. “Depression is associated with worse outcomes for conditions such as cardiac disease” (Taylor, 2014, p. 1228). With the symptoms the patient is experiencing such as memory disturbance, visuospatial skills, and impairments of decision-making potentially explains the late-onset of depression. Questions to ask the patient: To determine treatment for this patient, several questions would need to be asked such as: 1. How long have you been experiencing not feeling well? 2. Have you been feeling feverish? 3. How long have you been taking your medications that is mentioned? Are you taking any other medications such as OTC, herbal, or other prescription medications? And when was the last time you taken your medications? 4. What are your other past medical history such as: Cardiac, respiratory illness, urinary tract infections, diabetes, GI/GU issues, musculoskeletal issues, and endocrine issues. Psychological history such as: depression, anxiety, mood disorders, etc… 5. Any drug or alcohol use? Do you use tobacco products? 6. What is your dietary intake? How are your eating habits? How much water or other fluid intake in a day? 7. Family medical history? Asking family member’s questions such as: 1. Has your mother ever been aggressive? 2. Has she ever been diagnosed with depression or other psychological disorders? 3. What is her normal daily routine? 4. Has she ever experienced these symptoms before? Treatment: In order to correctly treat the patient, further diagnostics such as U/A, CBC, BMP, and Lipid panel should be drawn. Obtaining vital signs, complete physical assessment and neurological assessment. Assuming the patient is experiencing dehydration and also has a UTI, proper hydration such as IVF of normal saline or ½ normal saline bolus and antibiotics to treat infection. Certain antibiotics should be avoided due to inhibiting metabolism of Statins and increases toxicity; and avoid use of sulfa drugs if patient has allergy to sulfa. Recommended antibiotic would be Azithromycin. If the patient is experiencing depression, perhaps anti-depressant should also be given. Educating the patient on medication regimen such importance of hydration while on hydrochlorothiazide. Benton, D. & Young, H. A. (2015). Do small differences in hydration status affect mood and mental performance? Nutrition Reviews, 73(52), 83-96. doi: 10.1093/nutrit/nuv045 Edmunds, M. W. & Mayhews, M. S. (2013). Pharmacology for the primary care provider. (4th ed.). St. Louis, MO: Mosby Forsey, T. (2012). Can dehydration cause a urinary tract infection? Urinary Health Journal. Retrieved from: Taylor, W. D. (2014). Clinical practice: Depression in elderly. The New England Journal of Medicine, 37(13), 1228-36. doi: 10.1056/NEJMcp