NRS 410 PP-DQ5

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The case scenario provided will be used to answer the discussion questions that follow.

Case Scenario

Mr. C., a 32-year-old single man, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He reports that he has always been heavy, even as a small child, but he has gained about 100 pounds in the last 2–3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control with sodium restriction. He current works at a catalog telephone center.

Objective Data

Height: 68 inches; Weight 134.5 kg

BP: 172/96, HR 88, RR 26

Fasting Blood Glucose: 146/mg/dL

Total Cholesterol: 250mg/dL

Triglycerides: 312 mg/dL

HDL: 30 mg/dL

Critical Thinking Questions

What health risks associated with obesity does Mr. C. have? Is bariatric surgery an appropriate intervention? Why or why not?

Mr. C. has been diagnosed with peptic ulcer disease and the following medications have been ordered:

Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO 1 hour before bedtime and 3 hours after mealtime and at bedtime.

Ranitidine (Zantac) 300 mg PO at bedtime.

Sucralfate/Carafate 1 g or 10ml suspension (500mg / 5mL) 1 hour before meals and at bedtime.

The patient reports eating meals at 7 a.m., noon, and 6 p.m., and a bedtime snack at 10 p.m. Plan an administration schedule that will be most therapeutic and acceptable to the patient.

Assess each of Mr. C.’s functional health patterns using the information given. (Hint: Functional health patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance.)

What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

The health risk that Mr. C has are high blood pressure, sleep apnea, hyperlipidemia and most likely type 2 diabetes as indicated by the high fasting blood glucose, hgbA1c would give us a much better indication if this patient has diabetes. Bariatric surgery is an option for people that are considered extremely obese(BMI 40 or higher) or people who are considered obese (BMI 35-39.9) and have a serious weight related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea. Sometimes you can still qualify if your BMI is 30-34 and you have a serious weight related health problem (Mayo Clinic, 2014). Mr. C has a BMI of 47.6 and has high blood pressure and sleep apnea, Mr. C may also have type 2 diabetes. He meets the guidelines to qualify for bariatric surgery. Mr. C meets the guidelines but would still need to meet certain medical guidelines to qualify for the surgery and it would have to be decided if the benefits of having the surgery would outweigh the risk of the surgery. Mr. C would also

  • The health risk: HTN, sleep apnea, HLD, DM (maybe)
  • Bariatric surgery is a good option for him because he met guidelines for bariatric surgery. His BMI is 45, which is extremely obese (40 or higher) and he has high blood pressure, sleep apnea, and maybe diabetes. To get the surgery, the patient should be ready for physical and biological change. Consulting and counseling should be applied before the surgery.
  • Medication Plan:
    • Mylanta: 10am, 3pm, 9:30pm, bedtime
    • Zantac: bedtime
    • Sucralfate: 6am, 11am, 5pm, bedtime
  • Health Assessment
    • Health-perception/Health management: Patient feels that he is unhealthy and overweight and has some health issues. He could not follow a low sodium diet well.
    • Nutritional-metabolic: Mr. C. most likely has bad eating habit because he got 100lbs in past 2-3 years. He probably eats high sugar and fat because the blood test shows high glucose, high triglycerides, and high cholesterol. Having a evening snack can lead to weight gain.
    • Elimination: No information. The patient may take fewer fibers and have a difficulty for elimination due to high fat intake.
    • Activity-exercise: In working place, Mr. C. will sit down all the time. He may have sedentary lifestyle due to his weight and job position. He needs to move and walk to lose some weight for his health.
    • Sleep-rest: Mr. C. cannot get adequate sleep due to sleep apnea.
    • Cognitive-perceptual: No information. If it was developed well, he can prepare himself for bariatric surgery.
    • Self-perception/self-concept: Mr. C. may be uncomfortable due to his overweight.
    • Role-relationship: No information. Good relationship with support group can help the patient in many ways such as psychological support and moving help.
    • Sexuality-reproductive: No information. Due to heavy weight, the patient may have a difficulty in having a sexual relationship.
    • Coping-stress tolerance: No information. It will help the patient to deal with mental and physical stress when he gets bariatric surgery. It may also help to manage a low sodium diet well.
    • Value-Belief – No information. It will give spiritual cultural support to the patient.
  • Problems:
    • Coronary artery disease: Atherosclerosis may cause coronary artery disease.
    • Atherosclerosis: The patient’s cholesterol level is too high. I might cause atherosclerosis.
    • Sleep Apnea: The patient has sleep apnea, which may develop cardiovascular disease or cause accident due to lack of sleep.
    • Diabetes Mellitus: The patient is overweight and high fasting glucose level. It may lead lots of complication such as diabetic retinopathy.
    • Hypertension: The patient has high blood pressure and could not manage a low sodium diet. Uncontrolled high blood pressure can lead to stroke.

    have to be evaluated to see if he is psychologically ready to undergo the surgery and deal with all the changes after the surgery.

    Mr. C. has been diagnosed with peptic ulcer disease and the following medications have been ordered: (a) Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO 1 hour before bedtime and 3 hours after mealtime and at bedtime; (b) Ranitidine (Zantac) 300 mg PO at bedtime; and (c) Sucralfate / Carafate 1 g or 10ml suspension (500mg / 5mL) 1 hour before meals and at bedtime.

    The patient reports eating meals at 7 a.m., noon, and 6 p.m., and a bedtime snack at 10 p.m. Plan an administration schedule that will be most therapeutic and acceptable to the patient.

    6am Sucralfate/Carafate

    7am-meal

    10am- Mylanta

    11am- Sucralfate/Carafate

    Noon-meal

    3pm-Mylanta

    5pm- Sucralfate/Carafate

    6pm-meal

    9pm- Sucralfate/Carafate

    10pm-snack

    10:30 Mylanta

    Bedtime- Zantac, Sucralfate/Carafate

    Using sucralfate together with aluminum hydroxide/ magnesium hydroxide can decrease the effects of sucralfate. Sucralfate and aluminum hydroxide/magnesium hydroxide doses should be separated by at least half an hour (Drugs.com, 2014).

    Assess each of Mr. C.’s functional health patterns using the information given (Hint: Functional health patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance).

    What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

    Sleep apnea

    Obesity

    High blood pressure

    Coronary artery disease

    Class, I would like for you to discuss the differences among the common medications used to treat GERD, peptic ulcers or stress ulcers.

    Gerd: Baclofen may decrease the frequency of relaxations of the lower esophageal sphincter and therefore decrease gastroesophageal reflux. Antacids, H-2 receptor blockers and proton pump inhibitors.

    Peptic ulcer: Antibiotic with acid blocker or PPI. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline (Tetracycline HCL) and levofloxacin (Levaquin).

    Stress ulcer: Sucralfate is a polysaccharide that complexes with aluminum to prevent chemically induced mucosal damage and heal gastric ulcers. Misoprostol is a prostaglandin analog that selectively inhibits acid secretion as well as enhances mucosal defense mechanisms. Also antacids and PPI.

    Reference

    Peptic ulcer. (2016, September 01). Retrieved May 09, 2017, from http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/diagnosis-treatment/treatment/txc-20231747

    Initial treatments to control heartburn

    Over-the-counter treatments that may help control heartburn include:

    Contact your doctor if you need to take these medications for longer than two to three weeks or your symptoms are not relieved.

    • Antacids that neutralize stomach acid. Antacids, such as Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone won’t heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.
    • Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac). H-2-receptor blockers don’t act as quickly as antacids do, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions of these medications are available in prescription form.
    • Medications that block acid production and heal the esophagus. Proton pump inhibitors are stronger blockers of acid production than are H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec, Zegerid OTC).
    • Prescription-strength medications

      If heartburn persists despite initial approaches, your doctor may recommend prescription-strength medications, such as:

      These medications are generally well-tolerated, but long-term use may be associated with a slight increase in risk of bone fracture and vitamin B-12 deficiency.

      • Prescription-strength H-2-receptor blockers. These include prescription-strength cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac).
      • Prescription-strength proton pump inhibitors. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).
      • GERD medications are sometimes combined to increase effectiveness.

        • Medications to strengthen the lower esophageal sphincter. Baclofen may decrease the frequency of relaxations of the lower esophageal sphincter and therefore decrease gastroesophageal reflux. It has less of an effect than do proton pump inhibitors, but it might be used in severe reflux disease. Baclofen can be associated with significant side effects, most commonly fatigue or confusion.
        • Peptic ulcer

          Medications can include:

          The antibiotics used will be determined by where you live and current antibiotic resistance rates. You’ll likely need to take antibiotics for two weeks, as well as additional medications to reduce stomach acid, including a proton pump inhibitor and possibly bismuth subsalicylate (Pepto-Bismol).

          • Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline (Tetracycline HCL) and levofloxacin (Levaquin).
          • Long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk.

            • Medications that block acid production and promote healing. Proton pump inhibitors — also called PPIs — reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).
            • Available by prescription or over-the-counter, acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet HB) and nizatidine (Axid AR).

              • Medications to reduce acid production. Acid blockers — also called histamine (H-2) blockers — reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing.
              • Antacids can provide symptom relief, but generally aren’t used to heal your ulcer.

                • Antacids that neutralize stomach acid. Your doctor may include an antacid in your drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include constipation or diarrhea, depending on the main ingredients.
                • Options include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec).

                  • Medications that protect the lining of your stomach and small intestine. In some cases, your doctor may prescribe medications called cytoprotective agents that help protect the tissues that line your stomach and small intestine.
                  • Acid-Suppressive Agents
                    Acid-suppressive agents act either by reducing gastric acid or by protecting the stomach mucosa. Antacids are bases that contain aluminum, magnesium, or calcium that can temporarily neutralize gastric acid. These agents are normally indicated for minor symptoms of heartburn and acid-related indigestion. The major side effects of antacids include diarrhea for magnesium-containing compounds and constipation for aluminum- and calcium containing agents.

                    Sucralfate is a polysaccharide that complexes with aluminum to prevent chemically induced mucosal damage and heal gastric ulcers. Sucralfate does not alter the acid secretion of the stomach; rather, it stimulates the formation of granulation tissue and delivers growth factors to the injured tissue. Aluminum toxicity should be monitored when using sucralfate.

                    The use of misoprostol has been approved for the prevention of nonsteroidal anti-inflammatory-induced gastric ulcers. Misoprostol is a prostaglandin analog that selectively inhibits acid secretion as well as enhances mucosal defense mechanisms. Its use is contraindicated in women of childbearing potential, as it can lead to spontaneous abortion.4

                    H2RAs reduce acid secretion by blocking the histamine receptors on parietal cells. Currently 4 H2RAs are available in the United States (Table 1). The primary use of H2RAs is for the treatment of gastro esophageal reflux disease (GERD) and peptic ulcer disease (PUD).5

                    PPIs (Table 2) are more potent acid suppressing agents and are most commonly used for the treatment of PUD, GERD, and indigestion. These agents provide near-complete blockage of acid secretion by inhibiting the hydrogen-potassium ATPase pump on the parietal cell. All of the PPIs are weak bases that concentrate in the acidic compartments of the parietal cell. PPIs are then activated by the acid and subsequently form a reactive sulfhydryl group. This group binds to the cysteine moiety on the hydrogen-potassium ATPase pump and inactivates the enzyme.




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