Question

B.Y. is a 78 year-old woman that was brought to the ER of her local hospital when she developed symptoms of a stroke.  Her neighbor had checked on her and found that she couldn’t speak or move her right arm.  The neighbor knows B.Y. quite well and told the ambulance crew that B.Y. had stopped taking her Toprol XL a few weeks ago because it made her feel so tired.  She’d stopped taking her daily aspirin because it upset her stomach.  The Toprol XL was prescribed for atrial fibrillation and the aspirin to prevent clot formation from atrial fibrillation.

In the hospital, B.Y. was determined to have had a stroke and was admitted to the neuro floor for further treatment.  She was started on subcutaneous heparin and an intravenous beta blocker.  Because she was unable to swallow, a nasogastric tube was placed and she was started on 2 tablespoons of an antacid TID through the tube.  All further medications were given by the parenteral route, including a BID medication to prevent ulcers and a QID pain reliever. She also had an order for an acetaminophen rectal suppository, 500 mg., if fever of >101 degrees developed. On her third hospital day, she developed an arrhythmia and her physician ordered lidocaine to be given intravenously immediately.

1.  Why couldn’t B.Y.’s Toprol XL not have been crushed and given to her by nasogastric tube?

2.  What could have happened if B.Y.’s head was not raised for her TID antacid?

3.  What could happen if the nasogastric tube was not flushed after every dose of the antacid?

4.  How often was B.Y. to get the antacid?_______  How often did she get the pain reliever?________  

5.  What advantage, in general, do intravenous drugs have that enteral doses do not, in terms of gastrointestinal effects of drug absorption?

6.  What compliance issues did B.Y. have?

7.  What could have been done to prevent the above compliance issues?

8.  What conclusions about the ulcer prevention medications half-life could you reach, based of the dose frequency?  

9.  What kind of a drug classification is “beta blocker,” a therapeutic or pharmacological classification?

10.  Was a topical medication contraindicated with this patient?

11.  Which of her orders were “standing orders?”

12.  Were there any STAT orders for this patient?  Are/Is such an order(s) also single order(s)?  

13.  Which orders were routine orders?

14.  Did she have any prn orders?  If so, which ones were prn?

15.  How many milliliters per dose of the antacid did she get through her nasogastric tube?

Answer 1

1. Toprol- XL should be taken as prescribed by the practitioner. It should not be taken in larger or smaller amounts. It can be divided into half if prescribed so. The tablet should be swallowed whole and should not be chewed or crushed. Chewing or crushing will cause too much of drug to be released at one time.  
2. If the head end of the bed is not raised during nasogastric tube feeding can cause aspiration.
3. As we know antacids have thick viscosity, if not flushed it can get stuck in the tube itself and there will not be proper administration of the drug.
4. Antacid was prescribed for thrice a day 2 tablespoons. Pain reliever was given QID that is four times a day.