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Answers

258

■

Dyskinesia is when the individual develops a

series of involuntary movements, causing acute

embarrassment as they usually affect the face

and limbs. If the dose is lowered, the dyskine-

sia does stop, but is replaced by the rigidity it

had improved. This is a fine line that the patient

and doctor walk in order to accept the conse-

quences of both illness and treatment

■

The ‘on-off’ effect – this is where, quite sud-

denly, the drug therapy seems to stop working.

This can be quite distressing for the patient

and can sometimes occur when they are in the

middle of doing something. The reason for this

fluctuation is not fully understood, but patients

should be made aware of these side-effects

when commencing treatment

Case study

Younis Khan

■

Phenytoin interacts with many other medica-

tions, yet it is still an effective medication for

the control of epilepsy and has been started by

the consultant for a reason

Let us look at how it interacts with the other med-

ication on Younis’ list:

■

Insulin glargine – no listed interactions, so it is

safe to co-administer

■

Fluvastatin – interaction with lipid-regulating

drugs, specifically fluvastatin and colesevelam.

Consider changing lipid regulator to another

that does not interact, such as atorvastatin

■

Aspirin – phenytoin does interact with some

anticoagulants but not aspirin, so it is safe to

co-administer

All of the drugs Younis is taking are necessary

for his chronic conditions. He should be regularly

reviewed, and his medication monitored by the pre-

scribing professional.

Calculations

1 42 tablets

2 8mL

3 5mL

4 10mL

5 1.25mL

6 0.5mL

7 91 tablets

8 12.5mL

9 375mcg

10 15mL

Multiple-choice questions

1 b

2 a

3 c

4 c

5 a

6 b

7 d

8 b

9 a

10 c

Chapter 12

Case study

Debbie Butcher

Explain how SSRIs work as follows:

■

Checking Debbie’s knowledge, planning the

session, using understandable terms, using dia-

grams/models, and checking her understanding

of what you have told her

■

Discussing the monoamine theory of depression

■

Discussing what serotonin is and what is impli-

cated with regard to mood

■

Explaining what happens normally at a synapse

■

Explaining how SSRIs affect the re-uptake of

serotonin

Case study

Anil Kahn

Discussion around the action of atypical drugs

would including the following:

■

Drugs block the dopaminergic pathways in the

brain

■

Most typical antipsychotic medications act on

receptors

■

Most atypical antipsychotic medications act on

and D

receptors

https://t.me/medicina_free

Answers

259

Discussion around the difference between atypi-

cal and typical antipsychotics could include:

■

Typical drugs are associated with more side-

effects

■

Atypical drugs are better at dealing with nega-

tive symptoms of schizophrenia

■

Patients can gain weight and suffer secondary

diabetes if on atypical drugs

Case study

Rona McKenzie

Discussion should centre on the need to treat the

anxiety symptoms of the episode and identify the

specific triggers for the anxiety state:

■

Continuous treatment with SSRIs is not appro-

priate

■

Benzodiazepines are not recommended for this

type of anxiety

■

Beta blockers to manage the anxiety symptoms

would be the best pharmacological intervention

■

Relaxation or talking therapies may help

Case study

Lisa Ryman

Areas to consider include:

■

Lisa is likely to have anxiety-related episodes

throughout her life and benzodiazepines should

only be used in times of crisis and for a very

short time

■

Benzodiazepine use is related to poorer out-

comes in panic disorder; refer to BNF guidance

and NICE recommendations when explaining

this to Lisa and her mother

■

Suggest non-pharmacological strategies to deal

with the anxiety

■

Refer to experienced prescriber in autism spec-

trum disorder and anxiety if condition persists

for consideration of SSRI

Calculations

1 2 tablets

2 3 tablets

3 4 tablets

4 2.5 tablets

5 0.4mL

6 0.25mL

7 2.5mL

8 1mL

9 4mL

10 2.5mL

Multiple-choice questions

1 d

2 c

3 d

4 a

5 d

6 b

7 a

8 c

9 b

10 c

Chapter 13

Case study

Elizabeth Green

You may have included aspects of the following:

■

Cyclophosphamide is an example of an alkyl-

ating agent

■

Works directly on the DNA and prevents the cell

division process

■

Alkylating drugs are effective during all phases

of the cell cycle

■

Doxorubicin, which is a commonly used anthra-

cycline chemotherapy agent

■

Anthracyclines work by interacting with DNA

and inhibiting production and function

■

Fluorouracil is an antimetabolite which acts to

disrupt normal cellular division

Case study

Student nurse

You would probably offer the following information:

■

Aprepitant is used to control nausea and vom-

iting in patients undergoing cytotoxic therapy

■

It is an NK1 receptor antagonist and has its

action in the chemotactic trigger zone and the

vomiting centres of the brain

https://t.me/medicina_free

Answers

260

■

It is useful in the acute and delayed onset of

emesis in cytotoxic therapy

■

It is important to consider the drug interactions

of this drug, especially with warfarin

Calculations

1 3mg

2 46mg

3 0.7mg or 700mcg

4 2.5 hours

5 20 tablets

6 285mg

7 £4.21

8 15 doses

9 6 boxes

10 £1790.88

Multiple-choice questions

1 d

2 d

3 a

4 b

5 b

6 c

7 a

8 b

9 c

10 d

Chapter 14

Case study

Kubi Garise

Strategies to improve Mrs Garise’s compliance may

include:

■

Linking medication-taking with brushing teeth

in the morning and evening

■

Taking medications at coffee or tea breaks

■

Taking medications at the same time as a favour-

ite programme

■

Involving others in ensuring medicines are

taken

■

Placing notes or reminders around the house

■

Wearing an alarm watch that goes off when tab-

lets are due

■

Keeping a diary of when tablets have been taken

■

Using a pill organizing box

Case study

Ella Jenkins

Discussion around the importance of compliance

with the patient may include:

■

Checking the mother’s knowledge, planning the

session, using understandable terms, using dia-

grams/models, and checking her understanding

■

Ascertaining if Mrs Jenkins appreciates the

importance of Ella taking her medicine

■

Ascertaining if Mrs Jenkins understands the

consequences of Ella not taking her medicine

Improving Ella’s compliance with taking her med-

ication:

■

Consider looking at the formulation – can the

drug be given as a syrup which has a flavour

Ella likes?

Case study

Oliver Paresi

Discussion should centre on the following points:

■

His wife could help him with his medication but

she needs to be informed of the following:

■

the indication for each medication

■

the time each dose should be taken

■

the side-effects to look out for

■

the risk of not giving the medication

■

safe storage

■

Memory aids for Oliver to help him remember,

special packaging from the pharmacy or use of

reminder alarms

Calculations

1 2 tablets

2 2,500g

3 0.12mL

4 1,250,000mcg

5 2.5mL

6 2.5mL

7 200mL per hour

8 100,000mg

https://t.me/medicina_free

Answers

261

9 25g

10 300g

Multiple-choice questions

1 a

2 c

3 b

4 d

5 b

6 a

7 d

8 c

9 d

10 b

Chapter 15

Case study

Mr Ajani

■

The patient medicines administration chart is

not a prescription but a direction to administer

medication. It must be signed by a registered

prescriber and authorizes the delegation to

administer medication on the prescriber’s behalf

■

Check that the prescription chart is signed and

dated by the authorized prescriber

■

In exceptional circumstances, where medication

(not including controlled drugs) has been previ-

ously prescribed and the prescriber is unable to

issue a new prescription, but where changes to

the dose are considered necessary, information

technology (such as fax, text message or email)

may be used but must confirm any change to the

original prescription

Case study

Mrs Simpson

The nurse must have completed and passed an ac-

credited non-medical prescribing course to gain nota-

tion on her NMC registration as a V300 prescriber.

The fact the nurse is a prescriber and can issue

the prescription provides Mrs Simpson with more

rapid access to medication. This allows for service

improvement and greater patient satisfaction and

can promote improved patient–professional rela-

tionships. Even though Mrs Simpson could, in the-

ory, buy paracetamol over the counter, you should

bear the following in mind:

■

her ability to go shopping

■

the limited number of tablets she would be able

to buy in a pharmacy

■

the fact that Mrs Simpson is eligible for free pre-

scriptions

Case study

District nurse

The patient will be well known to the district nurse

if she visits regularly. Did the district nurse refer

to the patient’s notes when preparing for the visit?

Was there a photographic identifier on the notes?

Did the nurse greet the patient by name, and if so

did the patient respond? All of these things are pos-

sible, so it would be important as a student nurse

to ask the district nurse how she was sure she had

the correct patient. Had you been asked to do the

dressing and did not know the patient, it would have

been appropriate to carry out an identity check.

Case study

Josep Bosko

The discussion should include:

■

What are the licensed alternatives? There may

be another similar medication in liquid form

■

Prescribe an unlicensed alternative

■

Prescribe a specially formulated liquid alternative

■

Prescribe by another route. Are there supposi-

tory or patch formats?

Case Study

Max Jones

It is important to establish whether or not Max

has capacity to consent to medication treatment.

Although he is of a legal age to consent, his main dis-

ability may mean he lacks capacity. This means the

person administering the medication should assess

for capacity under the Mental Capacity Act 2005.

■

Can Max understand the information regarding

the need for medication?

■

Can he retain this information?

■

Can he use it to make a decision about whether

he wants to take the medication or not?

Ascertaining the above will help to determine

capacity and if it is found that Max lacks capacity,

https://t.me/medicina_free

Answers

262

then best interests and necessity should take prec-

edence. As his epilepsy is severe, it will be nec-

essary to give medication to prevent or reduce

seizure activity and this is in the best interests of

Max. If Max regularly refuses to take this essential

medication, then it is permissible to administer it

covertly.

Multiple-choice questions

1 b

2 a

3 d

4 a

5 c

6 c

7 b

8 a

9 d

10 b

https://t.me/medicina_free

263

Index

abacavir, HIV 76

abbreviations xix-xx

absence seizures 173, 174

absorption

ADME component 3-4, 10

age-related ADRs 21

children/adolescents 22

drug interactions 16, 21

physico-chemical factors 4

physiological factors 4

routes of drug administration 3

ACE inhibitors see angiotensin-converting enzyme

inhibitors

acenocoumarol, anticoagulant therapy 118-19

aciclovir, antiviral 78-9

aclidinium, COPD 135

acute coronary syndromes (ACS), blood

clotting 115-16

acute inflammation 96-7

acute pain 47-8

additive effects, adverse drug reactions (ADRs) 17

adherence see patient concordance

ADME, pharmacokinetics 3-6

adolescents see children/adolescents

adverse drug reactions (ADRs) 15-27