NURS350 Pharmacological Therapeutics Case Scenario Answer Document Case Scenario Answer Document Case Scenario Question Responses Spaces are provided below for your answers to the case scenario questions. Case scenarios have a varying number of questions. You may not need all of the spaces below if your case study has less than 7 questions. 1. In my understanding of nutrition, I believe Mrs. Jones is suffering from a vitamin A deficiency. Vitamin A is a fat- or lipid soluble vitamin and the function is visual pigments and epithelial cells. Vitamin A is also known as retinol and contains carotenes. Carotenes are precursors to Vitamin A that are converted to retinol in the wall of the small intestine once absorbed. Typically, vitamin A is obtained through a diet of leafy vegetables, butter, eggs, milk, and butter. However, since Mrs. Jones does not consume vegetables, that is likely the source of the deficiency. Lack of vitamin A for an extended period of time can result in night blindness, as well as enzyme results in night blindness. Lack of these vital sources in the diet over long periods of time may result in Vitamin A deficiency. Keto diet consists of low carb and high fat diet, with minimal vegetables and fruits allowed due to sugar content. It is possible her keto diet contributed to her deficiency. However, she stated that she doesn't like vegetables anyway so it could have been a deficiency before she started the keto diet, especially since symptoms of vitamin A deficiency don't usually present for some time and she's only been on keto for less than a year. Mrs. Jones aversion for vegetables and fruit lead to her not receiving sufficient amounts of beta carotene from whole foods, which convert retinol in the body. Mrs. Jones could have potentially still gotten Vitamin A from butter, milk, eggs, and liver. It's possible, though, that she was not consuming enough of it to counteract the effects of not consuming fruits and vegetables. Vegetables contain the highest source of Vitamin A in whole foods. A Keto diet was probably not the best choice for Mrs. Jones, due to already lacking vitamin A. The keto diet likely accelerated the progression of the night blindness, but I don't believe it was the initial cause. 2. I would expect the HCP to prescribe a vitamin A supplement. It could be started at 100,000 units/day for 3 days, followed by 50,000 units/day for two weeks, and finally 10,000-20,000 units/day for 2 months. Pregnancy risk is not a contraindication due to age. 3. I’m going to give you Atropine. It will help dilate the pupil, so I can see better. It will prevent the lens of the eye from moving while I am performing the exam. It will cause your vision to be blurry and you may have loss of near vision. These effects are to be expected and are temporary. Some adverse reactions include eye irritation and redness, dry mouth, local burning or stinging, headache, blurred vision, photosensitivity and dermatitis. These reactions are rare, but I want to let you know what to look out for. 4. Myopic drugs are classified as Cycloplegic: Anticholinergic. They dilate the pupil and paralyze the ciliary muscle and prevent lens from moving during assessment. They can cause severe blurred vision and loss of near vision. Mydriatic drugs are classified as Sympathomimetics. They are used to dilate the pupil for better visualization of the retina. They cause intense photophobia and pain in response to bright light. They are contraindicated for clients with glaucoma due to impairing aqueous humor outflow and NURS350 Pharmacological Therapeutics Case Scenario Answer Document increasing IOP. The effects of both classes of drugs can last as little as three hours up to several days. The patient should wear sunglasses and avoid driving, reading, and visual tasks during this time. 5. I would educate the patient of the adverse side effects and possible impairments that will occur during treatment. Adverse side effects include eye pain, photosensitivity, eye irritation, headache and more severe effects include hypertension, tremor, and dysrhythmias. She should wear sunglasses and be aware that the ability to drive, read, and perform visual tasks will be impaired. 6. Patient teaching would include the process of application, desired outcomes, benefits, adverse effects, frequency, and length of time she should use it. Topical corticosteroids (glucocorticoids) are preferred over oral or parenteral due to producing less side effects. Glucocorticoids provide slower release and absorption of the drug. High potency should be avoided in the head and neck regions due to potential adverse effects. Low potency is used for children. Medium is the best for Mrs. Jones condition due to the flare up being on her face. Special instructions for applying around eye area are to apply a thin line of ointment evenly along inner edge of lower lid margin, from inner to outer canthus. With a tissue, gently blot or remove excess medication around eye. Long-term use can cause redness, irritation, hypopigmentation, and thinning of skin. If absorption occurs, it can also produce adrenal insufficiency, mood changes, serum imbalances, and loss of bone mass. It’s important Mrs. Jones understands not to use the glucocorticoid longer than the prescribed time frame and to apply it exactly as prescribed. 7. Concept map below References for Responses and Concept Map NURS350 Pharmacological Therapeutics Case Scenario Answer Document References Adams, M., Ph.D., H. N., & Urban, C. (2019). Pharmacology for Nurses: A Pathophysiologic Approach (6th ed.). Pearson. Johnson, L. E. (2022, February 8). Vitamin A Deficiency. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/vitamin-adeficiency Night Blindness (Nyctalopia): Definition, Causes & Symptoms. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/symptoms/10118-night-blindness-nyctalopia Vitamin A deficiency. (n.d.). WHO. https://www.who.int/data/nutrition/nlis/info/vitamin-a-deficiency NURS350 Pharmacological Therapeutics Case Scenario Answer Document PHENYLEPHRINE Symptoms - Rapidly progressing night blindness Difficulty driving at night Patient Medical Diagnosis: Night Blindness Generic: retinol Key Assessments: Class: Retinoid Uses: Vitamin A deficiency Nursing Considerations: large doses may increase anticoagulant effects on warfarin, pregnancy risk category A at low doses, pregnancy risk category X at doses above RDA Adverse Effects: uncommon with recommended doses; acute ingestion causes CNS toxicity including headache, irritability, drowsiness, delirium, possible coma. Long term ingestion of high amounts cause dryness & scaling of skin, alopecia, fatigue, anorexia, vomiting and leukopenia. Chronic toxicity can cause liver impairment Trade: Mydfrin, Neo-Synephrine Class: Mydriatics: Sympathomimetics MOA: dilates pupil VITAMIN A SUPPLEMENT Trade: Aquasol A Generic: phenylephrine night blindness difficulty driving at night normal vision during day keto diet lack of fruits/vegetables in diet Past Medical History Uses: for eye examinations to allow better visual of retina Nursing Considerations: may damage contact lenses, pregnancy category C, driving, reading, visual tasks may be impaired Adverse Effects: eye pain, photosensitivity, eye irritation, headache and more severe effects include hypertension, tremor, and dysrhythmias GLUCOCORTICOID Generic: triamcinolone acetonide ATROPINE No past vision issues Trade: Aristocort, Kenalog Generic: atropine Class: Glucocorticoid Trade: Isopto Atropine MOA: inhibit phospholipase A2 on cell membrane Class: Cycloplegic: Anticholinergic Nursing Considerations: do not use longer than prescribed time frame & use caution to apply exactly as prescribed MOA: dilate pupils, paralyze ciliary muscle Uses: to prevent lens from moving during eye examinations Nursing Considerations: monitor pulse, reduce lighting to decrease photophobia; driving, reading, visual tasks will be impaired; wear sunglasses Adverse Effects: eye irritation, redness, dry mouth, local burning/stinging, headache, blurred vision, photosensitivity, eczematoid dermatitis. More severe effects include somnolence, tachycardia, convulsions, mental changes, keratitis, increased IOP Adverse Effects: Long-term use can cause redness, irritation, hypopigmentation, and thinning of skin. If absorption occurs, it can also produce adrenal insufficiency, mood changes, serum imbalances, and loss of bone mass
