Download Case Study: GERD

Case Study: Betty Sue
Betty Sue is 58 years old. She does not drink or smoke, walks daily and has a
BMI of 28. She recently completed a course of prednisone (Deltasone)
following a severe allergic reaction to a bee sting. Betty Sue tends to be
anxious and has had chronic GI problems. Betty Sue was recently was
diagnosed with an H.pylori infection along with a gastric ulcer. The provider
put her on ranitidine (Zantac) and sucralfate (Carafate) along with an
antibiotic.
1. What effect does Prednisone have on the GI lining and risk for ulcers?
2. How do the ranitidine and sucralfate work together to treat gastric ulcers?
3. What is the mechanism of action of ranitidine?
4. What is the mechanism of action of sucralfate?
5. How should Betty Sue be advised to take each of these medications?
Case Study: Betty Sue
At her follow up visit, Betty Sue reports that her stomach pain is gone
but she is having problems with constipation. First she tried some
psyllium fiber (Metamucil) but it made her feel bloated so she bought
some “white, chalky liquid stuff” at Dollar General. Now she is having
diarrhea every day. The provider gives her a prescription for
diphenoxylate/atropine (Lomotil) but tells her to only take it for a week.
1. What was the “white, chalky liquid stuff” that she has probably been
taking?
2. What is the mechanism of action of diphenoxylate/atropine?
3. Why did the provider limit its use to only a week?
4. What patient education can you do for the management of
constipation without medications?
Case Study: Betty Sue
Betty Sue’s stomach problems improve but her anxiety continues to worsen
and she reports, “No matter what I do, I just lose weight and I’m so hot all the
time”. Her provider draws labs and finds that her T3 and T4 are quite low
while her TSH is very high.
1. What is Betty Sue’s likely diagnosis?
2. What medication might be prescribed for her?
3. How will you know if the medication is working?
A few months into her treatment, Betty Sue trips and breaks her femur. The
ED draws her blood work and finds that she has a very high serum calcium
level.
1. What may be causing this elevated calcium level?
2. Why did she break her leg so easily?
3. What may need to be done to reverse this problem?
Case Study: Betty Sue
After having a partial thyroidectomy, Betty Sue has a normalized serum
calcium level but an elevated TSH level. She is put on a supplement of
calcium carbonate and Vitamin D to promote bone density and has a
prescription for levothyroxine (Synthroid).
1. What are the risk factors (adverse effects) of having too much
calcium in your body?
2. How should calcium supplements be taken to minimize both side
effects and adverse effects?
3. Why was she given levothyroxine after her surgery?
4. If the dosage of levothyroxine is appropriate, what will you see her
TSH level do?
Case Study: Nick
Nick is a 45 y.o. man who comes to the office with acid indigestion and
stomach pains every night. On doing his assessment, you find that he
drinks several beers and “a whiskey or two” every night, smokes 1 PPD of
cigarettes, has a BP of 146/92, and has a BMI of 34. He is diagnosed with
GERD and the provider gives him omeprazole (Prilosec) to take daily, and
tells him it’s okay to occasionally take Tums (calcium carbonate) or
Mylanta (aluminum hydroxide) as PRN.
1. What are Nick’s risk factors for GERD?
2. What patient education would you do regarding his risk factors?
3. When should he take the omeprazole?
4. How does omeprazole work?
5. How will you know if it is effective?
6. If ordered PRN, how should he take the Tums or Mylanta?
Case Study: Nick
Nick comes back to the office for a follow-up appointment and reports
that his GERD is much better but he has also been having problems with
frequent urination at night, and it seems that his urine volume is low.
Then he says, “Well really, I’m having problems in the bedroom too”. He
is examined and found to have an enlarged prostate gland. He is
prescribed tamsulosin (Flomax) and given a PRN of sildenafil (Viagra).
1. What is the purpose of the tamsulosin?
2. What are possible side effects of tamsulosin?
3. Can this patient take sildenafil?
4. What is the main contraindication to sildenafil?
Case Study: Nick
A week later Nick presents to the emergency room with severe RLQ
abdominal pain and acute appendicitis is confirmed on x-ray. He is taken
to surgery for an appendectomy. Afterward, he is given a morphine
pump and a PRN for odansetron (Zofran). After several days, he has not
had a bowel movement and the provider puts him on docusate (Colace)
and metaclopramide (Reglan).
1. What is odansetron for and how does it work?
2. What can you tell a patient to expect from taking docusate?
3. What does metaclopramide do?
The next day, Nick puts on the call light and reports that his face is
“twitching badly and I can’t control my mouth muscles”.
4. What medication may be causing this adverse drug reaction?
Case Study: Nick
During his hospital stay, Nick’s routine labs reveal a hemoglobin A1c
level of 9.8. He is diagnosed with Type II Diabetes. He doesn’t
understand how he can have diabetes develop at this point in his life.
His provider puts him on metformin (Glucophage) and glipizide
(Glucotrol XL).
1. What would you tell Nick about why he developed Type II DM?
2. What is the most common side effect of metformin and why does
that side effect occur?
3. What is an adverse risk from glipizide?
4. Could Nick take liraglutide (Victoza) and what would be a benefit for
him if he does?
Case Study: Nick
After starting his new medications, Nick puts on his call light to report
he feels “real shaky and like I’m jumping out of my skin”. The nurse
finds him to be diaphoretic and pale (cool & clammy) and a little bit
confused.
1. What is probably happening to Nick?
2. What two actions should the nurse take before contacting the
provider?
Case Study: Max
Maxine is a 28 year old woman who was recently diagnosed with late
onset Type I DM. She takes insulin glargine (Lantus) 45 units Qpm as
her only medication. You are working in the ED when Maxine is
admitted. She is agitated, confused and her skin is hot and flushed.
1. What do you suspect is going on with Maxine?
2. What other symptoms might you find when assessing this person?
3. What medication(s) will likely be administered and why?
4. Would Maxine benefit from taking glipizide? Why or why not?
Case Study: Max
After Maxine’s diabetes is more stable, she reveals that she is a
transgendered person and she wants to start making the transition to
male. Max is given weekly testosterone injections to assist in this
process.
1. What will you expect to see with testosterone supplementation?
2. What are the adverse effects that may occur?
3. What are the administration precautions that must be taken if the
testosterone is changed to a topical form?
4. How will testosterone (steroid) supplementation affect Max’s
diabetes and its management?
Case Study: Maria
Maria is 30 yrs. old and has been taking an estrogen/progestin conception
prevention medication (BCP) for 10-years. She has some mild depression
and puts herself on the herb St. John’s Wort at the advice of a friend.
Two months later she finds out that she is pregnant. Her pregnancy is
normal but at 28 weeks she starts to have some premature contractions.
The provider is concerned and she gives Maria terbutaline (Brethine) and
a week of oral prednisone (Delatosone).
1. Why did Maria get pregnant while taking BCP’s?
2. Why was Maria prescribed terbutaline at 28-weeks gestation?
3. How will you know if this medication is working?
4. Why was Maria prescribed prednisone?
Case Study: Maria
Maria’s contractions stop and her pregnancy progresses normally until 38
weeks when her BP starts to go up. She is admitted to the hospital and
given an oxytocin (Pitocin) IV drip. After 12 difficult hours, she gives birth
to a healthy baby but her BP spikes to 198/101. She is then put on a
Magnesium sulfate (MgSO4) IV drip and bed rest. Her BP drops as
expected but she becomes very groggy and has almost no deep tendon
reflexes, and her respirations drop to 10 breaths per minute.
1. What patient education should be done when oxytocin is used?
2. What are the typical side effects of MgSO4?
3. What are the serious adverse effects of MgSO4?
4. What should you, as a nurse, do if a patient has adverse effects to
MgSO4?
Case Study: Maria
Maria is only 32 when she is diagnosed with cervical cancer. Her
provider recommends that both ovaries be removed along with her
uterus. Post-operatively, she has difficulty in controlling her urgency to
void and to prevent accidents the provider gives her oxybutynin
(Detrol). Maria also chooses to take conjugated estrogen supplements
(Premarin).
1. What is the mechanism of action of oxybutynin?
2. What are the benefits of estrogen supplementation?
3. What are the risks of estrogen supplementation?
4. What is important patient education to provide?
Case Study: Tyler
Tyler is a 15 year old boy who has not developed any puberty changes
and he is only in the 55th percentile for height & weight in his age group.
Along with small stature, he also has hyperactivity and nocturnal
enuresis. His provider does a bone scan and finds that his epiphyseal
bone plates have not closed. He is put on somatropin (HGH) injections
once a week and given a prescription for desmopressin (Vasopressin)
orally to take at bedtime.
1. What assessment will be done to see if the somatropin is helping?
2. What was the importance of the bone scan prior to prescribing
somatropin?
3. What is the intended action of desmopressin?
4. How does desmopressin work?