drug interactions

By C.C. Pace RN, PHN from Paradise, CA on April 28, 2006
Category: Drugs & Medications

I have 51 year old female client who is ventilator dependant, quadriplegic (some gross upper arm movement) with GT nutrition ( 2 cans crucial and 2 cans isocal) and indwelling urinary catheter. She was diagnosed with ALS and has been on the LP-10 ventilator for 8 years. Her settings on the vent are Assist-Control with rate of 14, tidal volume of 0.9 l/min; inspiratory time of 1.2 sec. and humidifer 34 degrees C. She is cared for at home with Independant Nurse Providers, and her husband the primary caregiver. She has been deteriorating this last year, especially in her mental state. Even though she is quite alert and oriented, and directs her own care (we read her lips, and she talks around her trach (uncuffed Shiley 8.0)); she has been demonstrating increased irritability, anxiety, and depression and anger. She has been treated this year for lung and respiratory infections (serratia marcescens, pseudomonas aeruginosa, enterococcus faecalis, stenotrophomonas maltophilia, and staph aureus) with multiple IV and PO antibiotics. She is currently on tobi inhalation bid for 28 days.

Her routine medications are as follows: prevacid 30mg GT bid, estradiol 1mg GT qam, lactinex 4 tabs GT tid, zoloft 50mg GT qd, trazadone 150mg GT qhs, feso4 325mg GT bid, centrum silver 1 tbsp GT qd, vitamin B-12 500mcg GT qd, atrovent MDI 3 puffs/circuit QID (or HHN), flovent 220mcg 2 puffs/circuit bid, and 1 tsp/ 500ml water qd. Her prn meds are: benadryl 25-75mg GT qid, xanax 0.5mg GT 8xday, and either regular strength tylenol, tylenol #3 or tylenol #4 q4hrs (not to exceed 2400mg/day acetaminophen); zofran 4mg 1 q6hr prn nausea; reglan 5mg GT 1/2 hr before crucial feeding; miralax 1tbsp bid prn; bisacodyl 10mg prn. She receives 1000ml water daily, up to 500ml more for temp, or requested. She did have skin/blister reaction when last treated with Septra- but MD said to continue treatment due to difficulty with resistant organisms and we could treat her symptoms. On April 1, 2006 her RBC was found to be 2.28, H/H 7.8/22/6, and she was given 2 units PRBC. (WBC 6.3) Her chem panel at that time was : Na 137, K+ 3.5, Cl 110, CO2 20, glu 141, BUN 21.0, Cr 0.3; total bili 0.1, tot pro 9.2, albumin 2.5 , ALP 83, ALT (SGPT) 26, ans AST 12. She has refused repeat lab draw, as last visit to ER, she was stuck 8 times, (including for ABG) and they were unable to obtain sample. She does have a porta cath, and I am presently encouraging her to let me access this. She has been increasingly refusing/procrastinating care. She does have a small stage 2-3 decub on her left ischial tuberosity. She is on an air flow mattress, and is hydraulically lifted to electric wheelchair. Constipation is a problem, as is nausea. She requests 75mg benadryl, 0.5mg xanax, and tylenol #4 four times a day, at present.

I am concerned with this medication profiele ( in particular the possible serotonin level with trazadone, zoloft, and reglan; and also with the high use of diphenhydramine and codeine) especially with her unstable moods. Her blood pressure often runs 150-160's over 90's- 112. Her heart rate is usually in the 80's. and temp below 100 ( but receiving tylenol 4xd). What do you think of this regimen, any suggestions?

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