NU141 Unit 10 Final Medication Case Study Example

Six Drugs, One Fracture and the Risks as a Set: A Final Medication Case Study of a Composite 74-Year-Old Woman With a Spinal Compression Fracture Whose Home Sertraline and Lorazepam Meet a Hospital Opioid, Enoxaparin and, on Day Two, Tramadol

[Student Name]

Purdue University Global

NU141: Pharmacology for Nursing

Unit 10 Final Medication Case Study

[Instructor Name]

[Date]

The patient is composite; doses and values are bracketed where illustrative, and medication decisions belong to the prescriber and pharmacist.

The Patient and Her Medicines

[Mrs. F.], a composite 74-year-old retired seamstress, fell at home and has a compression fracture of a lumbar vertebra. Home medicines: sertraline [100] mg daily for depression and lorazepam [1] mg at bedtime for sleep, taken for years. Hospital orders on admission: oxycodone [5] mg every [4] hours as needed for pain, enoxaparin [40] mg daily for clot prevention, and her home medicines continued. On day two, because her pain remains [7] out of 10, tramadol [50] mg every [6] hours is added, and ondansetron [4] mg IV as needed for nausea. Her sodium on admission was [134] mmol/L. She lives alone, uses a cane outdoors and has no history of seizures.

Risk One: Serotonin Toxicity

Sertraline blocks serotonin reuptake; tramadol also inhibits serotonin reuptake in addition to its opioid action; ondansetron has serotonergic effects. Together they increase the risk of serotonin syndrome, which can cause agitation, confusion, tremor, muscle jerks, sweating, fever and a fast heart rate, and can become life-threatening (Boyer & Shannon, 2005). In an older woman, early signs could easily be mistaken for pain, anxiety or delirium.

Action: raise the combination with the prescriber and pharmacist before the first tramadol dose; if it is given, watch for tremor, muscle jerks, agitation and fever, and report them promptly.

Risk Two: Sedation and Breathing

Oxycodone, tramadol and lorazepam all depress the central nervous system. Opioids combined with benzodiazepines carry a recognized risk of profound sedation and respiratory depression. Her bedtime lorazepam, added to evening doses of two opioids, makes the night the period of highest risk. Increasing sedation usually precedes slowed breathing, so sedation is assessed along with respiratory rate (Jarzyna et al., 2011).

Each drug's dose is ordinary; the danger is that three of them arrive at bedtime together.

Action: assess sedation with a scale before each opioid dose and during the night; ask whether the lorazepam dose can be reduced or the timing separated from opioid doses; keep naloxone available.

Risk Three: Falls and Delirium

She was admitted because of a fall. Benzodiazepines, opioids and a new hospital environment all increase her risk of another fall and of delirium. A second fall could cause a new fracture.

Action: fall precautions, help with every transfer, a bed alarm at night, and daily screening for confusion; discuss with the prescriber whether tapering lorazepam is appropriate during or after the stay.

Risk Four: Bleeding

Enoxaparin prevents clots but increases bleeding risk, and SSRIs such as sertraline reduce platelet serotonin and can add to bleeding tendency, especially with anticoagulants.

Action: check for bruising, blood in urine or stool and bleeding at injection sites; monitor platelet count as ordered; avoid adding NSAIDs without review.

Risk Five: Low Sodium

SSRIs can cause hyponatremia, particularly in older women, and her sodium is already at the low end. Low sodium can cause confusion and unsteadiness, adding to fall risk.

Action: monitor sodium as ordered and report a falling value or new confusion. Because confusion from low sodium, from delirium and from serotonin toxicity can look alike at the bedside, any new confusion in Mrs. F. is reported with her full medication list and latest sodium, so the team can sort out the cause rather than simply adding another drug to calm her.

Why the List Must Be Read Together

Each order on its own was reasonable, and each prescriber, pharmacist and nurse who handled one drug could have judged it safe. The risks only appear when the whole list is read at once, which is why a nurse giving the first tramadol dose is in a strong position to notice them: the nurse sees every drug the patient receives across the day. For older adults, the course text stresses reviewing the complete list, including long-standing home medicines that may no longer be needed, such as a nightly benzodiazepine taken for years (Burchum & Rosenthal, 2022).

Priorities

The highest priorities are the combinations that can threaten life quickly: serotonin toxicity from adding tramadol to sertraline, and respiratory depression from opioids with lorazepam at night. Falls and delirium come next because they are likely and could cause serious injury. Bleeding and sodium are monitored and reported.

What Changed After Review

After the nurse raised the concerns, the pharmacist recommended against tramadol, and the prescriber instead scheduled acetaminophen around the clock with oxycodone for breakthrough pain, and a lumbar brace for comfort. Lorazepam was reduced to [0.5] mg. Mrs. F. had no further falls, her sedation scores stayed in the alert range, and her pain fell to [4] out of 10 by day four (Burchum & Rosenthal, 2022).

References

Boyer, E. W., & Shannon, M. (2005). The serotonin syndrome. The New England Journal of Medicine, 352(11), 1112-1120. https://doi.org/10.1056/NEJMra041867

Burchum, J. R., & Rosenthal, L. D. (2022). Lehne's pharmacology for nursing care (11th ed.). Elsevier.

Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L., Dempsey, S. J., Santangelo, D., & Polomano, R. C. (2011). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118-145. https://doi.org/10.1016/j.pmn.2011.06.008