Personalized Plan of Care

Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced the pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples. Suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.

  • Consider factors that might have influenced the patient’s pharmacokinetic and pharmacodynamic processes, such as genetics (including pharmacogenetics), gender, ethnicity, age, behavior, and/or possible pathophysiological changes due to disease.
  • Think about a personalized plan of care based on these influencing factors and patient history in your case study.

Case scenario:

AC is a 72-year-old male who is admitted to your ICU after suffering a massive stroke that has left him unresponsive and unable to communicate.  He is currently on a ventilator.  His wife of 48 years is available along with their one adult daughter.  The wife informs you that they don’t have any advanced directives, but she is “pretty sure her husband would not want to live like this.”  However, their daughter is adamant her dad would want to be kept alive in case there is any chance to come out of this.

Answer

Case Scenario

AC, a 72-year-old male, was admitted to the ICU after experiencing a massive stroke that had left him unresponsive and unable to communicate. Upon admission, he was placed on a ventilator. The patient’s wife of 48 years and their adult daughter were present. The wife stated they had no advanced directives, but she believed her husband would not want to live in his current state. However, the daughter was convinced her father would want to be kept alive if recovery was possible.

AC had a history of hypertension, hypercholesterolemia, and type 2 diabetes, according to his medical history. He also took various drugs, including lisinopril, metformin, and atorvastatin. Throughout his stay in the intensive care unit, the patient remained unresponsive. His neurological evaluation found no substantial improvement, and his CT scan revealed severe brain damage caused by the stroke. The patient’s vital signs were steady, and he did not appear to be in pain.

Pharmacokinetic and Pharmacodynamic Factors

Pharmacokinetic and pharmacodynamic variables are important determinants of a patient’s pharmaceutical response (Alagga & Gupta, 2022). Age, comorbidities, medication history, and organ dysfunction can all impact these factors in critically ill patients like AC. AC’s 72-year-old age may cause age-related changes in pharmacokinetics and pharmacodynamics, such as impaired renal and hepatic function, resulting in lower medication clearance and an increased risk of drug toxicity. His comorbidities of hypertension, hypercholesterolemia and type 2 diabetes may also impact pharmaceutical response by affecting drug metabolism and clearance. (Błeszyńska et al., 2020). His medication history, which includes lisinopril, metformin, and atorvastatin, may also result in drug interactions that impact pharmacokinetics and pharmacodynamics. AC’s stroke may have caused organ dysfunction, and using a ventilator may impact drug absorption, distribution, and elimination.

Personalized Plan of Care

The personalized care plan for AC would consider his medical history, age, comorbidities, medication history, and organ dysfunction. Since the patient is unresponsive and has conflicting views on his end-of-life wishes, the approach would prioritize his comfort, dignity, and quality of life while respecting his values and beliefs (Montmollin et al., 2021). The plan for managing AC’s medications would involve monitoring potential drug interactions and side effects. For example, atorvastatin and metformin may increase the risk of lactic acidosis, especially with renal impairment, so that renal function would be monitored and medication doses adjusted as needed (Alvarez et al., 2020). Moreover, drugs that may interfere with platelet function, such as aspirin or clopidogrel, would be avoided during a stroke due to the danger of bleeding.

AC’s stroke has caused brain damage and he is no longer responsive. The tailored treatment plan would prioritize comfort measures such as pain control, skin integrity, and infection prevention. Because AC is on a ventilator, precautions to prevent ventilator-associated pneumonia and other consequences are critical. (Papazian et al., 2020). However, if AC had comorbid conditions such as renal, heart, or liver failure, the personalized care plan would need to consider these factors, adjust medication doses, and monitor for signs of drug toxicity while managing fluid balance and electrolyte imbalances.

Without advanced directives, AC’s wife and daughter hold different views on his end-of-life care. The personalized care plan would involve a discussion with the family to understand AC’s values, beliefs, and wishes for end-of-life care (Gao et al., 2021). If his wishes are unclear, the care plan would prioritize comfort measures and aim to prevent suffering. If AC were younger, the care plan would focus on comfort measures. However, drug dosages may be adjusted according to his renal and hepatic function to achieve therapeutic levels while minimizing the risk of adverse effects.

 

References

Alagga, A. A., & Gupta, V. (2022, June 23). Drug absorption. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557405/

Alvarez, C. A., Halm, E. A., Pugh, M. J. V., McGuire, D. K., Hennessy, S., Miller, R. T., Lingvay, I., Vouri, S. M., Zullo, A. R., Yang, H., Chansard, M., & Mortensen, E. M. (2020). Lactic acidosis incidence with metformin in patients with type 2 diabetes and chronic kidney disease: A retrospective nested case‐control study. Endocrinology, Diabetes & Metabolism, 4(1), e00170. https://doi.org/10.1002/edm2.170

Błeszyńska, E., Wierucki, Ł., Zdrojewski, T., & Renke, M. (2020). Pharmacological Interactions in the Elderly. Medicina (Kaunas, Lithuania)56(7), 320. https://doi.org/10.3390/medicina56070320

Gao, L., Zhao, C. W., & Hwang, D. Y. (2021). End-of-Life Care Decision-Making in Stroke. Frontiers in Neurology, p. 12, 702833. https://doi.org/10.3389/fneur.2021.702833

Montmollin, E., Schwebel, C., Dupuis, C., Garrouste-Orgeas, M., da Silva, D., Azoulay, E., Laurent, V., Thiéry, G., Grinea, A., Marcotte, G., Oziel, J., Gainnier, M., Siami, S., Reignier, J., Sztrymf, B., Adrie, C., Ruckly, S., Sonneville, R., & Timsit, J.-F. (2021). Life Support Limitations in Mechanically Ventilated Stroke Patients. Critical Care Explorations, 3(2), e0341. https://doi.org/10.1097/cce.0000000000000341

Papazian, L., Klompas, M., & Luyt, C. E. (2020). Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Medicine46(5), 888–906. https://doi.org/10.1007/s00134-020-05980-0

 

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