B.L. is a 58-year-old white woman who has been referred for…

Question Answered step-by-step B.L. is a 58-year-old white woman who has been referred for… B.L. is a 58-year-old white woman who has been referred for pharmacotherapy assessment and diabetes management. Her multiple medical conditions include type 2 diabetes diagnosed in 1995, hypertension, hyperlipidemia, asthma, coronary artery disease, persistent peripheral edema, and longstanding musculoskeletal pain secondary to a motor vehicle accident. Her medical history includes atrial fibrillation with cardioversion, anemia, knee replacement, and multiple emergency room (ER) admissions for asthma.B.L.’s diabetes is currently being treated with a premixed preparation of 75% insulin lispro protamine suspension with 25% insulin lispro preparation (Humalog 75/25), 33 units before breakfast and 23 units before supper. She says she occasionally “takes a little more” insulin when she notes high blood glucose readings, but she has not been instructed on the use of an insulin adjustment algorithm.She denies use of nicotine, alcohol, or recreational drugs; has no known drug allergies; and is up to date on her immunizations.B.L.’s chief complaint now is increasing exacerbations of asthma and the need for prednisone tapers. She reports that during her last round of prednisone therapy, her blood glucose readings increased to the range of 300-400 mg/dl despite large decreases in her carbohydrate intake. She reports that she increases the frequency of her fluticasone MDI, salmeterol MDI, and albuterol MDI to four to five times/day when she has a flare-up. However, her husband has been out of work for more than a year, and their only source of income is her Social Security check. Therefore, she has been unable to purchase the fluticasone or salmeterol and has only been taking prednisone and albuterol for recent acute asthma exacerbations.B.L. reports eating three meals a day with a snack between supper and bedtime. Her largest meal is supper. She states that she counts her carbohydrate servings at each meal and is “watching what she eats.” She has not been able to exercise routinely for several weeks because of bad weather and her asthma.The memory printout from her blood glucose meter for the past 30 days shows a total of 53 tests with a mean blood glucose of 241 mg/dl (SD 74). With a premeal glucose target set at 70-140 mg/dl, there were no readings below target, 8% within target, and 91% above target. By comparison, her results from the same month 1 year ago averaged 112 mg/dl, with a high of 146 mg/dl and a low of 78 mg/dl.Physical ExamB.L. is well-appearing but obese and is in no acute distress. A limited physical exam reveals:●   Weight: 302 lb; height 5′1′′●   Blood pressure: 130/78 mmHg using a large adult cuff●   Pulse 88 bpm; respirations 22 per minute●   Lungs: clear to auscultation bilaterally without wheezing, rales, or rhonchi●   Lower extremities +1 pitting edema bilaterally; pulses good B.L. reports that on the days her feet swell the most, she is active and in an upright position throughout the day. Swelling worsens throughout the day, but by the next morning they are “skinny again.” She states that she makes the decision to take an extra furosemide tablet if her swelling is excessive and painful around lunch time; taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.Lab ResultsAbnormal or relevant labsHemoglobin A1c (A1C) measured 6 months ago: 7.0% (normal range: <5.9%; target: <7%)●   Creatinine: 0.7 mg/dl (normal range: 0.7-1.4 mg/dl)●   Blood urea nitrogen: 16 mg/dl (normal range: 7-21 mg/dl)●   Sodium: 140 mEq/l (normal range: 135-145 mEq/l)●   Potassium: 3.4 mg/dl (normal range: 3.5-5.3 mg/dl)●   Calcium: 8.2 mg/dl (normal range: 8.3-10.2 mg/dl)●   Lipid panel • Total cholesterol: 211 mg/dl (normal range <200 mg/dl) • HDL cholesterol: 52 mg/dl (normal range: 35-86 mg/dl; target: >55 mg/dl, female) • LDL cholesterol (calculated): 128 mg/dl (normal range: <130 mg/dl; target: <100 mg/dl) Initial LDL was 164 mg/dl. • Triglycerides: 154 mg/dl (normal range: <150 mg/dl; target: <150 mg/dl)●   Liver function panel: within normal limits●   Urinary albumin: <30 μg/mg (normal range: <30 μg/mg)PMH●   Poorly controlled, severe, persistent asthma●   Diabetes; control recently worsened by asthma exacerbations and treatment●   Dyslipidemia, elevated LDL cholesterol despite statin therapy●   Persistent lower-extremity edema despite diuretic therapy●   Hypokalemia, most likely drug-induced●   Hypertension stable●   Coronary artery disease, stable●   Obesity, stable●   Chronic pain secondary to previous injury, stable●   Status post-atrial fibrillation with cardioversion●   Status post-knee replacementPsychosocial:●   Financial constraints affecting medication behaviors●   Insufficient patient education regarding purposes and role of specific medications ●   Wellness, preventive, and routine monitoring issues: calcium/vitamin D supplement, magnesium supplement, depression screening, osteoporosis screening, dosage for daily aspirinMedication (Humalog 75/25), 33 units sq before breakfast and 23 units before supper. fluticasone metered dose inhaler (Flovent MDI), two puffs twice a day; salmeterol MDI (Serevent MDI), two puffs twice a day; naproxen (Naprosyn), 375 mg po twice a day; enteric-coated aspirin, 325 mg po daily; rosiglitazone (Avandia), 4 mg po daily; furosemide (Lasix), 80 mg po every morning; diltiazem (Cardizem CD), 180 mg po daily (per cardiologist consult); lanoxin (Digoxin), 0.25 mg po daily (per cardiologist consult); potassium chloride, 20 mEq po dailyfluvastatin (Lescol), 20 mg at bedtime.sublingual nitroglycerin for chest pain prn (has not been needed in the past month) furosemide, additional 40 mg po prn later in the day if needed for swelling (on most days the additional dose is needed); albuterol MDI (Proventil, Ventolin), two to four puffs every 4-6 hours prn for shortness of breath. Discussion 1.  What are reasonable outcomes for this patient?2.  Based on current guidelines and literature, pharmacology, and pathophysiology, what therapeutic endpoints would be needed to achieve these outcomes?3.  Are there potential medication-related problems that prevent these endpoints from being achieved?4.  What patient self-care behaviors and medication changes are needed to address the medication-related problems? What patient education interventions are needed to enhance achievement of these changes?5.  What monitoring parameters are needed to verify achievement of goals and detect side effects and toxicity, and how often should these parameters be monitored?  Health Science Science Nursing NURS 4412 Share QuestionEmailCopy link Comments (0)