care plan for pharmacy students

• Top 3:
o Delirium Tremens (DT)
o CHF (HFrEF)
o HIV
• Remaining Problems:
o COPD
o HTN
o VTE prophylaxis
o SUD
o GERD
o Obesity
Only top 3 problems need to be discussed and worked on like the example I provided.
Thank you. Also, please follow the instructions below:
1. Ensure Pros and Cons list include patient specific factors.
2. Be clear on recommendations – do not recommend “this” OR “that” – should make a decision and provide rationale for that decision.
3. Make sure that information in each section makes sense – do not put monitoring parameters in your assessment or goals of therapy – leave these for the monitoring section.
4. Do not copy and paste information into your care plans, even if they are cited. I am finding this is occurring too often and I am submitted all of these to Honor Council.
5. Your references on the last page must accurately map to the information you cited in your Care Plan – double and triple check these!

Complete Problem List:
1- Pyelonephritis
2- Pulmonary Embolism
3- Hyperglycemia
4- Acute on Chronic Kidney Disease
5- Hypertension
6- Peripheral Neuropathy
7- Anxiety
8- Hyperlipidemia

*Please only evaluate the top 3 problems*
Problems Evaluate Treatment Options
Problem 1:
Pyelonephritis Goals of therapy: The goal for this patient is to relieve symptoms within 48-72 hours, to prevent and treat pain associated with the infection, to eradicate the invading organism and prevent the recurrence of infection1.
Complicated because she has diabetes and it’s reached the kidneys
Assessment of Disease state:RG presented to the ER suffering from pain and burning on urinating and pain in the lower back. During physical exam, patient is presenting with signs and symptoms of UTI: fever (101F), chills and loss of appetite. Patient is also complaining from dysuria, urgency, frequency and flank pain. During neurological and psychiatry exam, patient is suffering from altered level of consciousness and confusion. RG’s urinalysis and CT scan results confirm that the patient is suffering from pyelonephritis. The patient’s urine is cloudy and yellow and shows the presence of nitrites. RG’s labs also show elevated WBC, blood and protein in urine, and leukocytes esterase. Given the patient’s age along with mental status change and severity of pain, patient should be initiated on antibiotic IV until stable and then switched to PO2.
Therapy Options: Fluoroquinolones IV/PO, Ceftriaxone IV, nitrofurantoin, trimethoprim/sulfamethoxazole are possible therapy options for this patient3. Selecting an appropriate therapy option for this patient is dependent on the severity of symptoms, complication of infection and antibiotic resistance.2
Fluoroquinolones1,2: Pros: Fluoroquinolones are reserved for pyelonephritis because of their activity. Cons: There’s a concern for the development of resistance among uropathogens. It also impairs glucose regulation.
Ceftriaxone4,5: Pros: well tolerated, broad spectrum and considered first line for complicated cystitis. Ceftriaxone is also the only cephalosporin that doesn’t need to be renally adjusted. It covers infections caused by E. coli, P. mirabilis, Proteus vulgaris, M. morganii, or K. pneumoniae. Cons: the drug is not available PO which would require change of therapy once the patient can be on oral therapy. High chance of developing C.diff is one side effect of this
Nitrofurantoin1,2,3: Pros: first line treatment option for lower UTI. It is also proven to achieve high urinary concentration. Cons: Since it doesn’t adequately penetrate the kidney tissues where the infection is for this patient, it shouldn’t be used as it won’t be effective. Also, for patients with CrCl less 30 based off the Beers criteria, it is not recommended for use in elderly patients.
Bactrim1,2,5: Pros: First line treatment for oral uncomplicated UTI therapy. Also recommended for oral therapy for complicated UTI. Cons: Mostly used orally. Due to increase resistance patterns, it should only be considered for specific pathogens and not for empiric treatment.

Recommendations (Pharmacologic)
Pharmacologic:1 Cetfriaxone IV 1 g once daily. Duration of therapy is 14 days. Patient can transition to oral therapy only after 24-48 hours of being afebrile. For oral therapy, I would recommend Trimethoprim/sulfamethoxazole (TMP/SMZ) 160/800mg PO BID for the remainder of treatment duration.

Rationale for Recommendation: Ceftriaxone is the best option given the patient’s renal function and age and type of UTI. Bactrim is the best option for oral therapy as it is mostly used as the first line therapy and doesn’t affect the patient’s other disease states.

Monitoring with Frequencies
Patient’s pain level and temperature should be monitored every 4 to 6 hours to assess therapy effectiveness. Patient’s fever should be monitored until patient is afebrile for 24-48 hours. Patient should have a CBC and urinalysis done after 48 hours or patient discharge to check for therapy effectiveness and confirm oral therapy. If patient’s symptoms don’t resolve within 48 hours, therapy should be altered and urine culture should be collected and examined for bacteria pathogen.
Problem 2:
Pulmonary Embolism
Goals of therapy: Initiate the patient on appropriate anticoagulation agents to treat their PE. Prevent complications of PE such as death. Improve quality of life

Assessment of Disease state: Patient was diagnosed 1 month ago and has been on anticoagulation with Rivaroxaban. After calculating the patient’s CrCl, Rivaroxaban is contraindicated and should be discontinued despite that the patient has been on it for a month.9,10
A new therapy should be initiated to prevent further complications.
Therapy Options:
Unfractionated heparin12: Pros: first line option in treating PE. antidote available. Injectable. Short half life. Cons: Requires continuous monitoring. Risk of bleeding. SE include thrombocytopenia, HIT, and hyperkalemia
Enoxaparin11
Pros: considered first line option. Has an antidote available. injectable.
Cons: black box warning; Neuraxial anesthesia. Needs renal adjustment since RG’s CrCL is 21 ml/min
DOACs13
Pros: first line oral therapy option for PE and PE prophylaxis because of their rapid onset of action and effectiveness.Cons: Patient’s renal function limits some of these options. Given the patient is hospitalized, there’s higher chances of drug accumulation and therefore higher chances of fatal bleeding risks.
Recommendations (Pharmacologic)
Pharmacologic: Discontinue Rivaroxaban and ibuprofen because of patient bleeding risk and patient’s age and CrCl. Initiate Tylenol 325mg for pain PRN.
Initiate the patient on Unfractionated Heparin with a bolus dose of 6,400 units and basal dose of 1,400 units10,12
After discharge, initiate the patient on Apixaban 2.5mg PO BID.
We needed to know if it was provoked or unprovoked esp because it’s a recent PE and the patient is still getting treated for it. That changes treatment duration. Renal impairment is a big deal here since the patient is on DOAC’s and these are heavily eliminated renally. Except apixaban
Rationale for Recommendation: UFH is the preferred treatment option for this patient given the patient age and renal function. The patient had success and been on DOACs before therefore Apixaban is the best option in this case.

Monitoring with Frequencies

Monitor patient’s hematocrit, hemoglobin, aPPT continuously during UFH therapy.10,12
Monitor for signs and symptoms of bleeding continuously.10,12
Monitor Hemoglobin, hematocrit, serum creatinine, liver function tests while on Apixaban.13

Problem 3: Hyperglycemia Goals of therapy:6,7,8 initiate patients on appropriate Anti-diabetic regimen to normalize their A1C. Keep patient asymptomatic and minimize all CV risk factors. Prevent long term macrovascular and microvascular complications

Assessment of Disease state: Patient has an A1C of 8.6% which is higher than their goal of 7% per ADA guidelines. Patient is currently on Glyburide 10mg 1 tablet orally daily and Metformin ER 1000mg 1 tablet orally BID and her A1C is still not controlled. Given the patient’s A1C, appropriate dual therapy needs to be initiated. Given the patient’s kidney function ( CrCl of 21 ml/min) Metformin is contraindicated. Patient needs appropriate agents to keep her glucose levels within range while in the hospital. Oral options may not be ideal since the patient is currently inpatient and in need of rapid treatment, injectables are more suitable.

Therapy Options6,7,8:
Insulin Pros: can be adjusted easily. Available in short and long acting. Patients can take it at home. Rapid onset. Cons: can lead to hypoglycemia. Injectable
GLP-1 agonists Pros: some agents in this class have been shown to reduce risk of CV outcomes
Cons: BBW for risk of thyroid C-cell carcinoma, risk of pancreatitis.

Recommendations (Pharmacologic)
Pharmacologic6,7,8:
• Initiate lantus 10 units subQ QD
• Adjust dose based on FBG while patient is in the hospital
o FBG> 180 mg/dl: Increase by 20% ot TDD
o FBG 14-18- mg/dl: Increase by 10% of TDD
o FBG 110-139 mg/dl: Increase by 1 unit
o FPG 40-70 mg/dL: decrease by 10-20%
o FPG <40 mg/dL: decrease by 20-40% • Discontinue Metformin due to patient CrCl and high risk of developing lactic acidosis Rationale for Recommendation6,7,8: Insulin is safer and easier to use since the patient is inpatient. given the patient’s A1C of 8.6%, the starting basal dose of insulin should be 0.2-0.3 units/kg/day or 10-5 units daily. Monitoring with Frequencies Monitor the patient’s blood glucose levels continuously since she is on insulin and blood glucose could change rapidly7. Monitor the patient for signs and symptoms of hypoglycemia. Those include confusion, shakiness, hunger, sweating, or tachycardia8. Recheck patient’s SCr and CrCl before discharge and if it’s more than 30 mL/min patient can go back on metformin but titrate up the dose while monitoring patient’s CrCl frequently after resolution of infection (every 4 weeks) References (with in-text citations): 1. Gupta K, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103-e120. 2. DiPiro, Joseph T. Pharmacotherapy –A Pathophysiologic Approach. 10th ed. Chapter 116: Urinary Tract Infections and Prostatitis (Access Pharmacy). 3. Colgan, R. Williams, M. Johnson J. Diagnosis and Treatment of Acute pyelonephritis in Women. Am Fam Physician 2011; 84(5):519-526. 4. Ramakrishan, K. Scheid, DC. Diagnosis and Management of Acute Pyelonephritis in Adults. Am Fam Physician 2005; 71(5):933-942. 5. Bactrim. Lexi-Drugs. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. Available at: http://online.lexi.com/crlonline. Accessed on: February 14, 2020. 6. American Association of Clinical Endocrinologists. (n.d.). Retrieved February 15, 2020, from https://www.aace.com/disease-state-resources/diabetes/slide-library/diagnosis-and-management-hyperglycemic-crises 7. American Diabetes Association. ADA. Retrieved on February 15, 2020. Diabetes Care. 2003;26:S109-S117 8. Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009, July 1). Hyperglycemic Crises in Adult Patients With Diabetes. Retrieved February 18, 2020, from https://care.diabetesjournals.org/content/32/7/1335 9. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST 2016; 149;315-352 10. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.Chest. 2012;141:e419S–494S. 11. Enoxaparin.Pharmacology. Elsevier/Gold Standard. Tampa, FL. Available at: http://www.clinicalpharmacology.com .Accessed February 17, 2020. 12. Heparin. Clinical Pharmacology. Elsevier/Gold Standard. Tampa, FL. Available at: http://www.clinicalpharmacology.com .Accessed February 17, 2020. 13. Ageno W, Gallus AS, Wittkowsky A, et al. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e44S–e88S. [PubMed: 22315269]