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Posted: April 13th, 2023
Pharmacokinetics and Pharmacodynamics
It is clear that you have a strong understanding of the importance of pharmacokinetics and pharmacodynamics in the context of advanced practice nursing. Your patient scenario highlights the various factors that can influence prescriptive decisions, such as age, genetics, and medical history. In this case, the patient's age, financial constraints, and multiple medical conditions are important considerations when developing a personalized plan of care.
Your personalized plan of care takes into account the patient's financial situation, potential medication interactions and side effects, and the need for medication monitoring. You also emphasize the importance of assessing memory and forgetfulness in older patients to ensure medication compliance.
In addition to the factors you have already considered, it may be helpful to involve the patient in the decision-making process and provide education on the medications being prescribed. This can help improve adherence to the treatment plan and empower the patient to take an active role in their healthcare.
Your approach to developing a personalized plan of care for this patient is comprehensive and well-informed. By considering the various factors that can influence prescriptive decisions and tailoring the treatment plan to the individual patient, you are demonstrating a high level of competence as an advanced practice nurse.
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As an advanced practice nurse, it is vital to develop a strong foundation of knowledge in the concepts of pharmacology. Pharmacokinetics and psychodynamics are understanding the basis of the reciprocal relationship between medications and the human body (Laureate Education, 2019; Rosenthal & Burchum, 2018). Factors that influence prescriptive decisions, such as age, genetics, and medical history are the basis of an individualized treatment while considering the advanced practice nurse comfort level in prescribing. Sabatino et al., (2017) explains that “formative education” enhances preparedness (p. 254). Therefore, in this discussion, I will present a patient scenario based on experience in the clinical setting describing factors that influence decision-making. Lastly, I will describe the details and provide examples of the personalized plan of care for the identified patient in the scenario considering influencing factors.
Patient Scenario
A 73-year-old Caucasian male presents to the community mental health outpatient clinic for medication follow up related to Post-Traumatic Stress Disorder (PTSD). The patient is a retired Vietnam Marine Combat Veteran. The patient served a two-year tour in Vietnam in the infantry division. The patient has a well-documented diagnosis of PTSD. The patient completed the PTSD therapy program. The patient’s problem list includes PTSD, insomnia, depression, hypertension, migraine headaches, and hyperlipidemia. The current medication list is as follows: Nortriptyline 10mg at bedtime, Propranolol 120mg daily, Amlodipine 5mg daily, and Atorvastatin 20mg with the evening meal. The medical and mental health conditions are well-controlled with medications. The patient is compliant with his primary care medical treatment. The patient is a non-smoker, with no history of alcohol or illicit drug abuse. The chart review reveals no known allergies. The patient's last EKG was within normal limits. The patient’s mini-mental exam was within normal limits. In the recent past, the patient reports an active lifestyle, including mountain climbing, target shooting, and hunting. However, the patient reports since his wife became chronically ill, he is not able to do the things he once enjoyed due to financial barriers and time constraints. The patient also reports he is the primary caretaker for his wife.
Factors Influencing Fundamental Concepts
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Prescribing decisions are influenced by pharmacokinetics and psychodynamics. In the given patient scenario, age is a crucial factor to consider. The absorption and distribution of medications can be affected by blood flow, making it essential to obtain a comprehensive health history in older adults to ensure that circulatory issues do not impede medication absorption or distribution.
In the aging adult population, drug metabolism tends to decrease with age. As mentioned by Rosenthal and Burchum (2018), older adult patients may require lower medication doses to avoid the risk of toxicity. Additionally, drug excretion also declines with age, primarily due to factors such as smaller kidneys, reduced nephrons, and changes in vessels that affect kidney blood flow (Rosenthal & Burchum, 2018, p. 24).
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Considering these age-related changes, healthcare providers must adjust their prescribing practices accordingly. Lower medication doses may be necessary to account for decreased drug metabolism and prevent adverse effects in older adult patients. Furthermore, healthcare professionals should also consider the potential impact of impaired kidney function on drug excretion and make appropriate dosage adjustments or consider alternative medications with less reliance on renal clearance.
In summary, when prescribing medications, healthcare providers must take into account the influence of pharmacokinetics and psychodynamics. In the patient scenario, age plays a significant role, as it affects medication absorption, distribution, metabolism, and excretion. Understanding these age-related changes is crucial to ensure appropriate dosing, prevent adverse effects, and optimize therapeutic outcomes in older adult patients.
Personalized Plan of Care
According to Rosenthal and Burchum (2018), there are multiple factors to consider in developing a personalized plan of care for a patient, such as: (1) cost, (2) treatment guidelines, (3) pharmacy formulary, (4) interactions, (5) side effects, (6) allergies to medications, (7) liver and kidney function, (8) age and (9) drug monitoring (p. 5-6). In this scenario, the first thing to consider is medication selection is cost and availability. The patient is retired, on a fixed income, and has financial constraints due to medical bills that occurred from his wife’s illness. A low-cost medication, readily available medication is key for compliance and wellness. Rosenthal and Burchum (2018) explain that even if a patient wants to be compliant, cost and availability may prohibit the patient from filling the prescription. Secondly, medication interactions and side effects are vital to consider in this 73-year-old patient. In the older patient population, polypharmacy increases the risk of side effects ( Lai & Fok, 2017). Medication monitoring should be included in the plan of care. The patient is currently taking Nortriptyline daily. According to Stahl (2017), EKG and lab monitoring is essential in the older population. In fact, a baseline EKG is recommended upon initial prescribing, and monitor plasma levels in the elderly (Stahl, 2017). Finally, an important factor to consider is assessing memory and forgetfulness. Rosenthal and Burchum (2018) explain a common reason for non-compliance with medication is forgetfulness or memory impairment. In this scenario, assessing memory and forgetfulness should take place at each visit considering the patient's age factor.
References
Lai, L., & Fok, M. (2017). Drug related problems and deprescribing in older adults. British Columbia Medical Journal, 59(3), 178-184. Retrieved from https://www.bcmj.org/articles/drug-related-problems-and-deprescribing-older-adults
Laureate Education (Producer). (2019). Pharmacotherapeutic concepts and challenges [Video file]. Baltimore, MD: Author.
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
Stahl, S. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide (6th ed.). New York, NY: Cambridge University Press.
Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017). Improving prescribing practices: A pharmacist‐led educational intervention for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 29(5), 248–254. doi:10.1002/2327-6924.12446
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