NURS-6521 Week 4: Assignment Case Studies

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

To Prepare:

Review the case study posted in “Announcements” by your Instructor for this Assignment

Review the information provided and answer questions posed in the case study

When recommending a medication, write out a complete prescription for the medication

Whenever possible, use clinical practice guidelines in developing your answers when possible

Include at least three references to support your answer and cite them in APA format.

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

SCENARIO 1

What are the errors in the following prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

fluticasone/salmeterol (Advair) 115/21 mcg 1 inhalation BID #1 Diskus 3 RF

albuterol 4 mg po 15-30 min before exercise #30 2 RF

budesonide/fluticasone (Symbicort) 160/4.5 mcg, 2 puffs inhaled BID and 1-2 puffs prn asthma symptoms (max 12 inhalations in 24 hours) #1 inhaler 2 RF

tiatropium (Spiriva Respimat) 2.5 mcg/actuation inhaler; inhale 2 actuations po once daily for COPD #1 inhaler/60 actuations 1 RF

lamotrigine (Keppra) 500 mg po BID #60 2 RF

 

SCENARIO 2

AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches. “I’m still getting migraines once a week, even though I take Ubrelvy when they start.” She reports experiencing 3 to 4 migraine attacks per month, typically associated with throbbing pain on one side, light sensitivity, and nausea. Migraines can last from 6-24 hours. AB has been taking Ubrelvy 50 mg po as needed at migraine onset for the past 3 months. She says it helps sometimes, but not consistently, and the pain often returns in a few hours. PMH: migraine without aura (diagnosed at age 27) Current medications: Ubrelvy 501mg po PRN at onset of migraine, ondansetron 4 mg ODT dissolve on tongue PRN nausea, may repeat in 8 hours if needed. Vitals: BP 118/74, HR 78. What treatment plan would you implement for AB? What medication changes would you make? How would you monitor the effectiveness of this plan, and what patient education would you provide? Is a patient with migraines more likely to start on an acute or preventive agent? What are examples of each?

 

SCENARIO 3

RC is a 58-year-old female that presents to the clinic today with early-onset Alzheimer’s Disease. What would you prescribe? Consider her labs and provide a drug therapy plan. Include complete medication orders. How would you monitor therapy? Labs: TSH 3.4 mU/L, vitamin D 22 ng/mL, B12 501 pg/mL, Hgb 12.8 g/dL, BG 96 mg/dL, A1C 5.9%, BP 115/72, HR 76. Medications include: Tresiba 15 units SC once daily QHS, Novolog 5 units SC before each meal TID (adjusting based on carbohydrate intake and glucose monitoring), and lisinopril 10 mg po daily

 

SCENARIO 4

PL is a 63-year-old male with poorly controlled type 2 diabetes presenting for follow-up and treatment optimization. Current medications include dicyclomine 10 mg po QID prn abdominal pain, pantoprazole 40 mg po daily 30 minutes before breakfast, losartan 50 mg po daily, and probiotics daily. His lab work today includes: BG 196 mg/dL, A1C  8.6%, K⁺ 4.2,  Cr 1.8, eGRF 27, BP 127/74. What treatment plan would you implement for PL (include complete medication order)? What is the classification and MOA of the drug you selected; why is it the best treatment option for PL? What education would you provide and how would you monitor the effectiveness of the treatment plan? What is his goal A1C?

 

 

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

WEEK 4: Gastrointestinal and Hepatobiliary System

Scenario 1: Medication Errors

Question:
What are the errors in the prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?

fluticasone/salmeterol (Advair) 115/21 mcg 1 inhalation BID #1 Diskus 3 RF

Error:
Incorrect dosage strength. Advair Diskus is available as 100/50, 250/50, or 500/50 mcg; 115/21 is the HFA inhaler formulation. The wrong device is specified.

Correct Prescription:

fluticasone/salmeterol (Advair Diskus) 250/50 mcg; inhale 1 puff by mouth twice daily. Dispense: 1 Diskus (60 doses). Refills: 3.

Classification:
Inhaled corticosteroid (ICS) + long-acting beta-2 agonist (LABA).

MOA:
Fluticasone decreases airway inflammation via glucocorticoid receptor activity (Remien & Bowman, 2024); salmeterol stimulates β2-adrenergic receptors, causing bronchodilation (Hsu & Bajaj, 2023).

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albuterol 4 mg po 15-30 min before exercise #30 2 RF

Error:
Oral albuterol is rarely used; inhalation is standard for exercise-induced bronchospasm.

Correct Prescription:

Albuterol sulfate HFA inhaler 90 mcg/actuation; inhale 2 puffs by mouth 15 minutes before exercise. Dispense: 1 inhaler (200 actuations). Refills: 2.

Classification:
Short-acting beta-2 agonist (SABA).

MOA:
Stimulates β2-adrenergic receptors in bronchial smooth muscle, leading to relaxation and rapid bronchodilation (Johnson & Bounds, 2024).

budesonide/fluticasone

(Symbicort) 160/4.5 mcg, 2 puffs inhaled BID and 1-2 puffs prn asthma symptoms (max 12 inhalations in 24 hours) 1 inhaler 2 RF

Error:
Medication incorrectly written as “budesonide/fluticasone.” Should be budesonide/formoterol. PRN dosing is only indicated in SMART (single maintenance and reliever therapy) but requires clarification.

Correct Prescription:

Budesonide/formoterol (Symbicort) 160/4.5 mcg; inhale 2 puffs by mouth twice daily and 1 puff as needed for asthma symptoms, maximum 12 inhalations per 24 hours. Dispense: 1 inhaler (120 actuations). Refills: 2.

Classification:
ICS + LABA.

MOA:
Budesonide reduces airway inflammation; formoterol is a rapid-acting LABA that provides bronchodilation (Lipworth et al., 2024).

tiotropium (Spiriva Respimat) 2.5 mcg/actuation inhaler; inhale 2 actuations po once daily for COPD #1 inhaler/60 actuations 1 RF

Error:
Route written incorrectly as “po” (oral); should be “by inhalation.”

Correct Prescription:

Tiotropium (Spiriva Respimat) 2.5 mcg/actuation; inhale 2 actuations (5 mcg total) by mouth once daily. Dispense: 1 inhaler (60 actuations). Refills: 1.

Classification:
Long-acting muscarinic antagonist (LAMA).

MOA:
Blocks M3 muscarinic receptors in airway smooth muscle, preventing acetylcholine-mediated bronchoconstriction (Delgado & Bajaj, 2022).

lamotrigine (Keppra) 500 mg po BID #60 2 RF

Error:
Wrong drug name. Lamotrigine (Lamictal) and levetiracetam (Keppra) are two different drugs. Incorrect combination written.

Correct Prescription (assuming levetiracetam intended):

Levetiracetam (Keppra) 500 mg; take 1 tablet by mouth twice daily. Dispense: 60 tablets. Refills: 2.

Classification:
Antiepileptic (broad-spectrum).

MOA:
Modulates synaptic neurotransmitter release by binding to synaptic vesicle protein SV2A, stabilizing neuronal activity (Contreras-García et al., 2022).

Scenario 2: Migraine (AB, 34 years old)

Treatment Plan & Medication Changes

AB continues to experience migraines 3–4 times per month despite acute therapy with Ubrelvy. Since migraines are frequent and disruptive, preventive therapy is warranted per AHS guidelines (American Headache Society, 2024). For this case, I will optimize acute therapy (Ubrelvy) and continue an antiemetic.

Prescriptions

Preventive
– Propranolol LA 60 mg PO once daily.

Sig: Take 1 capsule by mouth daily.

Disp: 30 capsules. Refills: 2.

Acute
– Ubrogepant (Ubrelvy) 50 mg PO PRN.

Sig: Take 1 tablet by mouth at onset of migraine; may repeat in 2 hours if needed (max 200 mg/24 hrs).

Disp: 16 tablets. Refills: 2.

Antiemetic
– Ondansetron ODT 4 mg.

Sig: Dissolve 1 tablet under the tongue PRN for nausea; may repeat in 8 hours.

Disp: 20 tablets. Refills: 1.

Classification & MOA

Propranolol
: Non-selective β-blocker; reduces frequency of migraines by stabilizing vascular tone and decreasing excitability (Jeong et al., 2024).

Ubrogepant
: CGRP receptor antagonist; blocks neuropeptide-mediated vasodilation and pain signaling (Boinpally et al., 2024).

Ondansetron
: 5-HT3 receptor antagonist; blocks serotonin-mediated nausea pathways (Theriot & Ashurst, 2019).

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

Monitoring & Education

Maintain headache diary (frequency, triggers, severity).

Monitor Blood pressure and heart rate for propranolol side effects.

Education: Avoid migraine triggers (caffeine, skipped meals, poor sleep, stress).

Follow-up in 6–8 weeks to assess frequency reduction (goal ≥50% reduction in migraine days).

Scenario 3: Early-Onset Alzheimer’s (RC, 58 years old)

RC is a 58-year-old woman with early-onset Alzheimer’s disease. Her labs are stable, except for a vitamin D deficiency. She has a history of diabetes (on insulin therapy) and hypertension (on lisinopril). Management should address cognitive decline and vitamin D deficiency while ensuring safety with her current regimen.

Prescription & Drug Therapy Plan

Cognitive Symptoms – Alzheimer’s Disease

Donepezil 5 mg PO once daily at bedtime

Mechanism: Acetylcholinesterase inhibitor increases acetylcholine in the brain, slowing cognitive decline (Marucci et al., 2020).

Prescription

Medication:
Donepezil 5 mg tablets (Aricept or generic)

Sig:
Take one (1) tablet by mouth once daily at bedtime
.

Quantity
: 30 tablets (30-day supply)

Refills:
2

Special Instructions:
Take at bedtime. May be taken with or without food. Monitor for nausea, diarrhea, insomnia, dizziness, or slow heart rate. Contact the clinic if fainting, palpitations, or severe GI upset occur.

Titrate to 10 mg PO once daily after 4–6 weeks if tolerated.

Vitamin D Deficiency

Cholecalciferol (Vitamin D3) 2000 IU PO once daily

Mechanism: Restores vitamin D levels, improves bone health, and may support cognition (Al-Hashimi & Abraham, 2024).

Prescription

Medication:
Cholecalciferol (Vitamin D3) 2000 IU capsules/tablets

Sig:
Take one (1) capsule by mouth once daily.

Quantity:
30 capsules (30-day supply)

Refills:
2

Special Instructions:
Take with food to improve absorption. Recheck vitamin D level in 3 months.

Continue current medications

Tresiba 15 units SC QHS.

Novolog 5 units SC TID before meals (with carbohydrate adjustments).

Lisinopril 10 mg PO once daily.

Monitoring Plan

Cognition & function:
Use MMSE or MoCA every 6–12 months.

Adverse effects of donepezil:
Monitor for nausea, diarrhea, bradycardia, and insomnia. Check HR regularly (Kumar et al., 2023).

Labs:

Vitamin D level in 3 months.

Continue routine diabetes labs (A1C every 3–6 months, BG logs).

Renal function (BMP) annually with lisinopril and insulin use.

Blood pressure & HR:
Monitor for hypotension or bradycardia.

Family/caregiver input:
Monitor changes in memory, ADLs, and mood.

Scenario 4: Poorly Controlled Type 2 Diabetes (PL, 63 years old)

Because PL has type 2 diabetes with CKD (eGFR 27), metformin is contraindicated (risk of lactic acidosis), and SGLT2 inhibitors are not recommended at this level of kidney function. The best choice is a GLP-1 receptor agonist, which lowers A1C, reduces CV risk, and is safe in reduced renal function (Adamczak et al., 2024).

Prescription:

Medication:
Dulaglutide (Trulicity) 0.75 mg/0.5 mL prefilled pen

Sig (Directions):
Inject 0.75 mg subcutaneously once weekly.

Quantity:
4 pens (28-day supply)

Refills:
2

Special Instructions:
Administer on the same day each week, with or without meals. Rotate injection sites (abdomen, thigh, upper arm). Do not share pens.

Drug Classification & Mechanism of Action (MOA)

Class:
GLP-1 receptor agonist

MOA:
Mimics incretin hormone GLP-1, enhances glucose-dependent insulin secretion, suppresses glucagon secretion, slows gastric emptying, and increases satiety, which lowers A1C and promotes weight loss (Ayesh et al., 2024).

NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.

Education for PL

Common side effects: nausea, vomiting, diarrhea (usually improve after the first week).

Eat smaller, more frequent meals to reduce GI upset.

Monitor blood sugar regularly; keep a log.

Report symptoms of pancreatitis (severe abdominal pain, persistent nausea/vomiting).

Continuing lifestyle modifications (low-carb diet, exercise as tolerated).

Monitoring Plan

Blood glucose logs
: monitor fasting and postprandial BG.

A1C:
repeat in 3 months (goal:
<7% , individualized; with CKD and age, <7.5–8% may be reasonable). Renal function: monitor serum creatinine/eGFR every 3–6 months. BP: continue losartan for renal protection. Weight and GI tolerance: track during follow-up visits. Goal A1C: <7% (per ADA), but <7.5–8% may be safer given CKD, age, and comorbidities (ElSayed et al., 2024).   References Adamczak, M., Kurnatowska, I., Naumnik, B., Stompór, T., Tylicki, L., & Krajewska, M. (2024). Pharmacological nephroprotection in chronic kidney disease patients with type 2 diabetes mellitus—Clinical practice position statement of the Polish Society of Nephrology. International Journal of Molecular Sciences , 25 (23), 12941–12941. https://doi.org/10.3390/ijms252312941 Al-Hashimi, N., & Abraham, S. (2024, January 10). Cholecalciferol . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549768/ American Headache Society. (2024). Preventative migraine treatment . American Headache Society. https://americanheadachesociety.org/resources/primary-care/preventative-migraine-treatment Ayesh, H., Suhail, S., Ayesh, S., & Niswender, K. (2024). Comparative efficacy and safety of weekly Dulaglutide versus weekly insulin in type 2 Diabetes: A network meta-analysis of randomized clinical trials. Metabolism Open , 100284–100284. https://doi.org/10.1016/j.metop.2024.100284 Boinpally, R., Shebley, M., & Trugman, J. (2024). Ubrogepant: Mechanism of action, clinical and translational science. Clinical and Translational Science , 17 (1), e13675. https://doi.org/10.1111/cts.13675 Contreras-García, I. J., Cárdenas-Rodríguez, N., Romo-Mancillas, A., Bandala, C., Zamudio, S. R., Gómez-Manzo, S., Hernández-Ochoa, B., Mendoza-Torreblanca, J. G., & Pichardo-Macías, L. A. (2022). Levetiracetam mechanisms of action: From molecules to systems. Pharmaceuticals , 15 (4), 475. https://doi.org/10.3390/ph15040475 Delgado, B. J., & Bajaj, T. (2022). Tiotropium . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541127/ ElSayed, N. A., McCoy, R. G., Aleppo, G., Balapattabi, K., Beverly, E. A., Early, K. B., Bruemmer, D., Echouffo-Tcheugui, J. B., Ekhlaspour, L., Garg, R., Khunti, K., Lal, R., Lingvay, I., Matfin, G., Napoli, N., Pandya, N., Pekas, E. J., Pilla, S. J., Polsky, S., & Segal, A. R. (2024). Older adults: Standards of care in diabetes—2025. Diabetes Care , 48 (Supplement_1), S266–S282. https://doi.org/10.2337/dc25-s013 Hsu, E., & Bajaj, T. (2023, June 20). Beta 2 Agonists . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542249/ Jeong, E., Mogos, M. F., & Chen, Y. (2024). Stroke risk reduction in migraine patients using propranolol: Evidence from two large-scale real-world data analyses. MedRxiv (Cold Spring Harbor Laboratory) . https://doi.org/10.1101/2024.06.11.24308801 Johnson, D. B., & Bounds, C. G. (2024, January 10). Albuterol . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482272/ Kumar, A., Sharma, S., & Gupta, V. (2023). Donepezil . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513257/ Lipworth, B., Kuo, C. R., Stewart, K., & Chan, R. (2024). Budesonide/formoterol or budesonide/albuterol as an anti-inflammatory reliever therapy for asthma. The Journal of Allergy and Clinical Immunology: In Practice . https://doi.org/10.1016/j.jaip.2024.02.003 Marucci, G., Buccioni, M., Ben, D. D., Lambertucci, C., Volpini, R., & Amenta, F. (2020). Efficacy of Acetylcholinesterase Inhibitors in Alzheimer’s Disease. Neuropharmacology , 190 (1), 108352. https://doi.org/10.1016/j.neuropharm.2020.108352 Remien, K., & Bowman, A. (2024). Fluticasone . PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542161/ Theriot, J., & Ashurst, J. V. (2019). Antiemetic serotonin-5-HT3 receptor blockers . National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513318/ NURS-6521 Week 4: Assignment Case Studies – Pharmacology concepts for the gastrointestinal and hepatobiliary systems.