Nicholas Browne

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Due date: 12/4/2010 @ 5pm
Words Count: 1472
HNN215 Quality Use of Medicines in Nursing

Table of Contents
Question 1.........................................................................................................................................3
Question 2.........................................................................................................................................5
Question3..........................................................................................................................................8
Question 4.......................................................................................................................................10
References.......................................................................................................................................11

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HNN215 Quality Use of Medicines in Nursing

Question 1

Cefaclor SR

Cefacolr SR is a second-generation cephalosporin, which is a sustained released antibiotic.

Cephalosporin is related to beta-lactam, which penicillin also belongs to (Pharmaceutical

Society of Australia, 2010). This requires caution when the patient is allergic to penicillin, as

3%-10% of patients will have a cross reaction with cephalosporin’s (Clinical Pharmacologly,

2010). Cefaclor works by interfering with bacteria cell wall, which leads to the cell dying.

The bacteria cell wall synthesis is prohibited by penicillin-binding proteins (Clinical

Pharmacologly, 2010). Cefaclor SR is the reason that Cefaclor is being used for Mrs Seville is

due to recent chest infection, to help prevent any new infections forming after the surgry

due to her weakened immune system.

Tramadol SR

Tramadol is an opioid analgesic, used for moderate to severe pain. Tramadol is active in pain

management by acting upon the mu opioid receptors and prevents the reuptake of

noradrenalin and serotonin(Pharmaceutical Society of Australia, 2010). 60% of the tramadol

is metabolised by the liver, with bioavailability after 6 hours approximately 95% with the use

of the sustained release(Clinical Pharmacologly, 2010). Food does not affect the rate of

tramadols absorption; however it is recommended that it is taken in a consistent manor,

either with or without food (Clinical Pharmacologly, 2010). Tramadol is being used to

manage post-operative pain.

Gentamycin

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Gentamycin has been prescribed to Mrs Seville to help prevent infection, due to her hip

surgery. Gentamycin is a broad gram-negative spectrum antibaticial, which works via

prohibiting the protein synthesis (Pharmaceutical Society of Australia, 2010). The majority of

gentamycin eliminated by kidneys as gentamycin is not metabolised. The half life of the

gentamycin, is generally 2-3hours, provided the patient has normal renal function (Clinical

Pharmacology, 2010).

Amitriptyline

Amitriptyline is an antidepressant, which is also acceptable to be used to assist in the

management of pain, as in the case with Mrs Seville. Amitriptyline is classed as a Tricyclics

antidepressant, which inhibits the reuptake of noradrenalin and serotonin (Pharmaceutical

Society of Australia, 2010). It is metabolised in the liver, which converts it from

Amitriptyline to nortiptyline, which allows it to be able to cross the blood-brain barrier.

After 24 hours 25-50% of the dose of Amitriptyline would have be excreted through the

urine (Clinical Pharmacology, 2010).

Celecoxib

Celecoxib is a selective COX-2 nonsteroidal anti-inflammatory drugs (NSAID). Celecoxib

works by inhibiting the synthesis of prostaglandins, by inhibiting the COX-2 (cyclo-oxyenase)

which produces an anti-inflammatory and analgesic response (Pharmaceutical Society of

Australia, 2010). Celecoxib is metabolised in the liver, where 97% of the celecoxib being

metabolised. The peak plasma concentrations occur 3 hours after the oral dose of celecoxib

is administered. If celecoxib is taken with fatty foods, the peak plasma is delayed (Clinical

Pharmacology, 2010).

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HNN215 Quality Use of Medicines in Nursing

Question 2

Quality use of medicines

Quality use of medicines

Amitriptyline Yes

Cefaclor SR No

Celecoxib Yes

Enoxaparin Yes

Gentamycin Yes

Ginko No

Panadeine Forte No

Paracetamol Yes

Tramadol SR Yes

Risk of Allergic reaction to Cefaclor

Mrs Seville is at an increase risk of suffering an allergic reaction Cefaclor, due to her previous

anaphylaxis reaction to penicillin (Pichichero, 2006). Under the quality use of medicines,

this fails to provide a safe and appropriate treatment due to the potential risks, which out

way the benefits when there is a more appropriate medication (National Medicines Policy,

2000). Pichichero (2006) states that Cefaclor is unsafe cephalosporin due to having a similar

side chain to penicillin, however other cephalosporin could be used safely.

The use of Ginko and NSAID

Ginkgo (Ginko) has been known to contain antiplatelet which is of concern when Mrs Seville

is taking Celecoxib, a NSAID (Abebe, 2002). The reason for concern is that it increases the

risk of bleeding, greater than aspirin taken alone. Ginkgo also decreases the analgesic affect

of the NSAID, due to the inhibitory effect on the thromboxane synthesis (Abebe, 2002).

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HNN215 Quality Use of Medicines in Nursing

These affects and interaction between the ginkgo and the Celecoxib means that there are

undesirable side effects, and is not the quality use of medicines due to the fact that it

increases Mrs Seville risk of post-operative haemorrhage (Abebe, 2002).

Use of paracetamol and panadeine forte together.

Mrs Seville is at risk of paracetamol overdose when she is on her current home medications,

due to the taking both her Panamax (paracetamol) and Panadeine forte (paracetamol with

codeine) with her evening medicines (Pharmaceutical Society of Australia, 2010). This

results in a higher than recommend doses within the 4 – 6 hourly window, where only 1g is

recommend compared to Mrs Sevilles 2g she is taking each evening (Pharmaceutical Society

of Australia, 2010). This increases her risk of liver complications and could result in an

adverse event, and can lead to increased risk of renal failure (Waring, Jamie, & Leggett,

2010).

Risk of serotonin toxicity/syndrome

There is an increase risk that Mrs Seville could be exposed to serotonin toxicity, which can

lead to serotonin syndrome. The increased risk is due to Mrs Seville being prescribed

multiple medicines which increase CNS serotonergic activity (Ringland et al.2008).In Mrs

Sevilles case the Tramadol, and Amitriptyline increase the risk of serotonin syndrome

(Haanpää et al. 2010). According to Horn & Hansten (2009, p25) mild cases of serotonin

syndrome can still impair quality of life due to sleep disruption and agitation. Although rare,

Serotonin syndrome has in some cases proven to be fatal when the signs and symptoms have

been ignored (Haanpää et al. 2010).

The use of Panadeine Forte when Mrs Seville suffers from asthma

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Panadeine forte contains codeine, which the Pharmaceutical Society of Australia (2010)

states that extreme caution must be used when the patient has asthma. Under the quality

use of medicines, when there is a more appropriate medication available, this should be

used, as it provides better outcomes for Mrs Seville (National Medicines Policy, 2000). As

Mrs Seville has mild asthma, there is a risk that it can increase the likely hood of an asthma

attack and worsen her quality of life due to worsening asthma.

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Question3

To reduce the risk of an allergic reaction to Cefaclor, another cephalosporin should be used

or the Roxithromycin which was originally use, and ordered for her use during her stay on

the ward (Pichichero, 2006). Roxithromycin would be the ideal drug in this case as it has

been proven to be safe when a patient suffers from a penicillin allergy (Pharmaceutical

Society of Australia, 2010, p.18). The nurse would need to discuss this case with the

prescribing doctor or the pharmacist to ensure the quality use of medicines is being

achieved as there may be better alternative medication as suggested above.

To prevent the risk of bleeding and post-operative haemorrhage the nurse should disuses

the increase risk of taking Ginkgo with Mrs Seville. The nurse should encourage Mrs Seville

to have the Ginkgo withheld during her hospitalisation and until she is off the Celecoxib

(Abebe, 2002). This will be able to provide a better quality use of medicines, due to the

decreased risk of haemorrhage and provides the most benefit for Mrs Seville in the short

term.

To help reduce Mrs Sevilles risk of paracetamol overdose, the nurse would need to educate

Mrs Seville on how Panamax and Panadeine forte both contain paracetamol. The nurse

should explain that Mrs Seville should only take either the Panamax or the Panadeine forte

within a 4-6hour window, depending on her pain levels experienced at the time, with

Panadeine forte for stronger pain (Pickering, Estrade, Dubray, 2005, p707). Mrs Seville also

should understand that she is only able to take a maximum of 4 grams of paracetamol a day,

which is equal to maximum 8 tablets (Pickering, Estrade, Dubray, 2005, p707).

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When caring for Mrs Seville the nurse needs to be monitoring her for any signs and

symptoms of serotonin syndrome, to help prevent the serotonin toxicity developing and to

insure her quality of life is not affected. Close (2005. P79) states there need to be at least

three of the signs and symptoms, which include a change in their mental state, agitation,

shivering, tremor, diarrhoea, incoordiation, fever, diaphoresis, hyperreflexia and myoclonus.

In the event that serotonin syndrome is detected it can clear in as little as 24 hours

(Haanpää et al. 2010).

To reduce the risk of an asthma attack or worsening symptoms which are related to

Panadeine forte, another pain relief should be used considered. The nurse would need to

discuss this case with the prescribing doctor or the pharmacist to ensure the quality use of

medicines is being achieved, and the new more appropriate medication ordered for her use

during her stay on the ward. Tramadol SR may prove to be a more appropriate medication,

as it does not affect the repertory system as greatly compared to over opioids

(Pharmaceutical Society of Australia, 2010).

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Question 4

Genta levels are required to ensure that the gentamycin remains within the

therapeutic range and is used to help prevent toxicity levels reaching a critical point where

Nephrotoxicity , vestibular (balance and spatial awareness) and auditory (hearing) toxicity

causing irreparable damage (Therapeutic Guidelines, 2010). Gentamicin levels require

monitoring for changes in their vestibular and auditory, with a baseline audiometry levels

taken (Therapeutic Guidelines, 2010). In order for the nurse to be able to monitor any changes

in the vestibular system they should ask Mrs Seville about any atatxia, disequilibrium and

loss of balance, oscillopsia any loss of visual activity during any head movement. To help

prevent Nephrotoxicity, serum creatinine levels also need to be monitored, and creatinine

clearance needs to be calculated, to ensure that the appropriate starting dose and to ensure

renal function is stable (Therapeutic Guidelines, 2010).

In the event that Mrs Seville will be on gentamycin for more than two days, plasma

levels also need to be taken and monitored, to help reduce the onset of nephrotoxicity and

also it helps to reduce the risk of vestibular and auditory toxicity ( Therapeutic Guidelines,

2010). Unlike vestibular and auditory toxicity, nephrotoxicity is normally reversible.

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References

Abebe, W, 2002, ‘Herbal medication: potential for adverse interactions with analgesic

drugs.’ Journal of Clinical Pharmacy & Therapeutics, Vol. 27, No.6, p 391-401, retrieved 2nd

April 2010 Academic Search Complete.

Clinical Pharmacologly, 2010, Gold Standard, Retrieved 8th April 2010, <http://www.

clinicalpharmacology-ip.com.ezproxy-f.deakin.edu.au/default.aspx>

Close, B, 2005, ‘Tramadol: does it have a role in emergency medicine?’, Emergency Medicine

Australasia, Vol 17, No.1, p73-83, retrieved 2nd April 2010, CINAHL with Full Text database.

Haanpää, M Gourlay, M, Kent, J, Miaskowski, C, Raja, S, Schmader, K & Wells, C 2010,

‘Treatment Considerations for Patients With Neuropathic Pain and Other Medical

Comorbidities’, Mayo Clinic Proceedings, Vol. 85, pS15-S25, retrieved 2nd April 2010,

Health Source: Nursing/Academic Edition

Horn, J., & Hansten, P. 2009, ‘Tramadol and Serotonin Syndrome’. Pharmacy Times, Vol.75,

No. 25, p25, Retrieved 1st April, Academic Search Complete database.

‘National Medicines Policy’, 2000, Commonwealth of Australia, Retrieved 1st April,

<www. nmp.health.gov.au/pdf/nmp2000.pdf>

Pharmaceutical Society of Australia, 2010, ‘Australian Medical Handbook’, Pharmaceutical

Society of Australia, Adelaide.

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Pichichero, M, 2006, ‘Cephalosporins can be prescribed safely for penicillin-allergic

patients’, Journal of Family Practice, Vol. 55, No.2, P106-113, Retrieved 5th April,

from Academic Search Complete database.

Pickering, G, Estrade, M, & Dubray, C, 2005, ‘Comparative trial of tramadol/paracetamol and

codeine/paracetamol combination tablets on the vigilance of healthy volunteers’,

Fundamental & Clinical Pharmacology, Vol.19, No.6, p707-711, Retrieved 10th April,

Academic Search Complete.

Ringland, Clare, Andrea Mant, Patricia McGettigan, Philip Mitchell, Christopher

Kelman, Nicholas Buckley, & Sallie-Anne Pearson, 2008, ‘Uncovering the potential

risk of serotonin toxicity in Australian veterans using pharmaceutical claims data’,

British Journal of Clinical Pharmacology, Vol.66, no. 5, p682-688. Retrieved 6th April,

Academic Search Complete.

Therapeutic Guidelines, 2010, eTG complete, <http://ezproxy.deakin.edu.au/login?url

=http://etg.tg.com.au/conc/tgc.htm?id=682f7a09b0a275b32f9a52d564f6d7e7>

Waring, W, Jamie, H, & Leggett, G, 2010, ‘Delayed onset of acute renal failure after

significant paracetamol overdose: A case series’, Human & Experimental Toxicology,

Vol.29, No.1, p63-68, Retrieved 5th April, from Academic Search Complete database.

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