CaseStudyBrochureStaff

Case Study
Pharmacology Review

Common Medications after a
Stroke / Cerebrovascular Accident

Presented by:
Rebelene Miranda, BsCN

Ryerson University
Faculty Advisor: Dr. Don Rose

Presented to:
North York General Hospital (Neurology and Stroke Unit) Nursing Staff/

Students

Case Study

An 80-year old male with history of hypertension and
hyperlipidemia was brought to the Emergency Room with sudden onset
of right side weakness and imbalance, followed by decreased level of
consciousness. CTA revealed an occlusion of the left MCA stem. He
received Alteplase IV tPA and steroids in the Emergency Room. He was
transferred to the Neurology and Stroke Unit where he will be continued
to be monitored. Patient passed swallowing test and was ordered a
heart healthy diet.

Ordered medications are:
(Fragmin) Dalteparin 5000 IU SQ BID
(Lipitor) Atorvastatin 80mg PO OD
(Tenormin) Atenolol 50 mg PO OD

ANTI-COAGULANTS

Action Contraindication Side/Adverse Effects Nursing Considerations

Anticoagulants interfere • Hemophilia and related • Diarrhea Assessment
with blood clotting by disorders. • Rash • Monitor blood tests (Hct, platelets, occult
preventing clot • Fever. blood in stools) q3mo
formation. • Leukemia with bleeding • Hemorrhage • Monitor PTT, which should be 1½-2 3
• Peptic ulcer disease • Agranulocytosis control, PPT; daily, APTT, ACT, INR
• Thrombocytopenic • Leukopenia • Monitor B/P; watch for increasing signs of
• Eosinophilia hypertension
purpura • Thrombocytopenia • Monitor for bleeding gums, petechiae,
• Blood dyscrasias ecchymosis, black tarry stools, hematuria
• Acute nephritis • Monitor for fever, skin rash, urticaria
• Subacute bacterial • Monitor for needed dosage change q1-
2wk
endocarditis
Patient/family education
Precautions: Anticoagulants • Advise patient to avoid OTC preparations
should be used with caution that may cause serious product interactions
in pregnancy, geriatric, and unless directed by prescriber
alcoholism. • Inform patient that product may be held
during active bleeding (menstruation),
Common Drugs Interactions depending on condition
• Caution patient to use soft-bristle
• Argatroban Salicylates, steroids, toothbrush to prevent bleeding gums; avoid
contact sports; use electric razor
• Dabigatran and nonsteroidal anti- • Instruct patient to carry/wear emergency
ID identifying product taken
• Dalteparin (high alert) inflammatories will • Instruct patient to report any signs of
bleeding: gums, under skin, urine, stools
• Enoxaparin (high alert) potentiate the action of

• Fondaparinux anticoagulants

• Heparin (high alert)

• Lepirudin (high alert)

• Tinzaparin (high alert),

• Warfarin (high alert)

Evaluation Positive therapeutic outcome
• Decrease of DVT

ANTI-LIPIDEMICS

Action Contraindication Side/Adverse Effects Nursing Considerations

Controls/Decreases cholesterol • Persons breastfeeding • Headache, Assessment
levels. • Obtain a diet and lifestyle history,
(some products) • Dizziness including exercise, smoking,
alcohol, and stress-related
• hypersensitivity to any • Fatigue activities

product • Insomnia Patient/family education
• Teach patient all aspects of
• Severe hepatic disease • Peripheral edema medication use
• Instruct patient to combine
• Anti-lipidemics are • Dysrhythmias medication with lifestyle changes,
including low-cholesterol diet,
identified as pregnancy • Sinusitis decreasing LDL in diet; avoid
smoking, alcohol, and sedentary
category X on some • Pharyngitis daily routine

products. • Abdominal pain Evaluation Positive therapeutic
outcome
• Diarrhea • Decrease in triglycerides and LDL
cholesterol levels
Precautions: • Constipation

Some products are • Flatulence

identified as pregnancy • Back pain.

category C.

Common Drugs Interactions

HMG-CoA reductase inhibitors: Interactions vary
atorvastatin, fluvastatin, widely among products.
lovastatin, pitavastatin, Check individual mono-
pravastatin, simvastatin graphs for specific
information.
Bile acid sequestrants:
cholestyramine, colesevelam

Miscellaneous:
ezetimibe, fenofibrate, fenofibric
acid, gemfibrozil, niacin,
niacinamide

BLOOD PRESSURE MEDICATIONS

ACE Inhibitors Action Contraindication Interaction Side / Adverse Nursing Considerations
Effects
Dilates arterial and venous • Hypersensitivity Interactions Assessment
vessels resulting in decrease of reactions may vary • Hypotension • MONITOR PULSE AND BP PRIOR
blood pressure. occur widely among • Bradycardia
products. • Tachycardia TO ADMINISTRATION
Common Suffix: —pril • Allergies Check • Headache • Monitor blood tests: neutrophil or
Common Drugs should be individual • nausea, and low platelets
identified mono-graphs • Monitor renal function: protein,
benazepril, enalapril, fosinopril, for specific vomiting. BUN, creatinine; watch for increased
lisinopril, quinapril, ramipril, • Should not be information. levels, which may indicate nephrotic
used in Side effects and syndrome; obtain baselines in
Beta Blockers Action children or in adverse renal/hepatic function tests before
Action: Reduces heart rate, force patients with reactions may beginning treatment
of contraction and blood heart block. vary widely • Assess for feet and legs edema
pressure. between classes • Identify allergic reaction, inc. rash,
Precautions: and specific fever, pruritus, urticaria: product
Common Suffix: –olol Use with caution products. should be discontinued if
Common Drugs in geriatric and antihistamines fail to help
dialysis patients, • Place patient • Identify symptoms of CHF: edema,
atenolol, betaxolol, esmolol, and in the in supine or dyspnea, wet crackles, B/P
metoprolol presence of Trendelenburg • Assess for renal symptoms:
Calcium Channel Blockers Action hypovolemia, position for polyuria, oliguria, frequency
Relaxes the blood vessels leukemia, and severe Patient/family education
causing a decrease in blood electrolyte hypotension • Instruct patient to comply with
pressure. imbalances. schedule, even if feeling better
• Advise patient to rise slowly to
Common Suffix: –pine sitting or standing position to
minimize orthostatic hypotension
Common Drugs Evaluation Positive therapeutic
outcome
Amlodipine, diltiazem, • Decrease in B/P in hypertension
felodipine, isradipine, • Decreased B/P, edema, moist
nicardipine, crackles in CHF.
nifedipine, verapamil

THANK YOU FOR PARTICIPATING!

References and Resources on Medication Administration:

College of Nurses of Ontario. (2017). Practice standard: Medication. Retrieved September 16,
2017, from http://www.cno.org/globalassets/docs/prac/41007_medication.pdf

North York General Hospital Centre for Education. (2013). Nursing students and teachers’
handbook. Retrieved September 13, 2017, from
http://www.nygh.on.ca/data/2/rec_docs/1342_Nursing_Student__Teacher_Handbook_N
ov_2013.pdf

North York General Hospital. (2012). Guidelines to clinical care for preceptored students and
clinical instructors. Retrieved September 15, 2017, from
http://www.nygh.on.ca/cernercbt/files%5CCLINICAL%20CARE%20MODULE%20-
%20April%202012.pdf

North York General Hospital. (2016). North York general hospital policy manual.
Retrieved September 16, 2017, from http://nygh.on.ca/data/2/rec_docs/2692_11857_II-
290_Orders_Management_Policy_-_July_2016_-_NA.pdf

Skidmore-Roth, L. (2015). Mosby's drug guide for nursing students (11th ed.). Saint Louis, MO:
Elsevier. Washington, G. T. (2013). The theory of interpersonal relations applied to the
Preceptor–New graduate relationship. Journal for Nurses in Professional Development,
29(1), 24-29. doi:10.1097/NND.0b013e31827d0a8

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K. H., Townsend, M. C., & Gould, B. (2008).
Brunner and Suddarth’s textbook of medicalsurgical nursing 10th edition. Philadelphia:
Lipincott Williams & Wilkins.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis's drug guide for nurses.
Philadelphia: F.A. Davis.