A33-year-old Caucasian female with a history of depression,.
A33-year-old Caucasian female with a history of depression,… A33-year-old Caucasian female with a history of depression, addiction, obesity, metabolic non-fatty liver disease, hypertension, and chronic acetaminophen use presented to the ED with jaundice and abdominal pain. Patient had the gastric bypass surgery 3 years ago. This patient had a recent newly diagnosis of alcohol abuse after a divorce and continued acetaminophen use for frequent headaches related to the hypertension and symptoms related to the alcohol use. The patient was not on any medications as the co-morbidities had ceased with the weight loss of 145 pounds. The patient was on many medications prior to weight loss. “Metabolic Non-fatty Liver Disease medication therapy is the fate of nanocarriers and related safety issues following administration through various routes, with reports of inflammation-related DNA damage in the liver associated with exposure to nanoparticles” (Assi, 2021). Also, obesity-related metabolic syndrome can result in the liver volume causing ineffective drug metabolism (Assi, 2021). Patient weighed 125 on the day of admission, however an accumulation of body fluid was related to 18 pounds of excess weight. According to Lorico, multiple pharmacokinetic changes occur after gastric bypass surgery (2020). These changes include impaired gastric motility, gastric fluid volume decreases, gastric fluid PH becomes basic, medications will have less contact with bile secretions, drugs bypass carrier proteins, and the proximal small intestine has a high concentration of CYP3A4 enzymes6 (Lorico, 2020). The results of these changes result in dosage adjustments, mainly decreasing doses. Literature reads that clinicians and researchers are observing that some patients stop overeating and instead acquire new compulsive disorders such as alcoholism (Santos, 2016). This patient was drinking daily, consuming 1 liter of wine a night. Considering the obesity-related metabolic syndrome, the liver volume causes ineffective drug metabolism (Assi, 2021). Also, according to Lorico, absorption kinetics of drugs changes for individuals post gastric bypass surgery (2020). There is also a higher maximum alcohol concentration in gastric bypass patients, faster and higher blood alcohol concentration and the rate of delivery of oral alcohol blood into the circulation is increased by gastric bypass, and the alimentary bolus reaches jejunum faster. Also, the gastric volume is reduced, alcohol dehydrogenase, which influences first step of alcohol metabolism is also less available resulting in an accumulation of the substance in the body due to a decrease in excretion time. (Briegleb, 2020). Acetaminophen is absorbed from the gastrointestinal tract and is metabolized in the liver and kidney by cytochrome P-450 (CYP) enzymes (Chrois, 2020). Adding the acetaminophen to the body, along with the alcohol resulted in liver damage. The patient was admitted to the hospital and hypertension from the liver failure became a concern. The patient was being assisted with hygiene and when the patient was rolled over in the bed, she had a heart attack and deceased! It was devastating to see a woman so young with conditions related to addiction and over the counter medications leave behind two young girls and a newly established marriage. With the metabolic changes that had occurred with the liver related to obesity and medication along with the liver toxicity that took place as a result of lack of knowledge, depression, addiction, and ineffective metabolism of an over-the-counter medication, the effects were paid at a high price, life. PLAN OF CAREA thorough on-going assessment by the primary physician should be essential. With the consideration of new addictions being common after gastric bypass surgery, education concerning this issue is optimal. Medications need to be assessed and over-the-counter medications need to be specifically assessed and the acetaminophen use would have needed to be addressed (Rosental, 2021). I was not aware of the rule that no one is to consume more that 4 grams of acetaminophen within a 24-hour period until I became a nurse! The public needs to know this information. Also, inquiring as to why the patient chose this medication and introduction of a safer medication should have been implemented to control the hypertension symptoms. Portal hypertension due to the liver failure most likely was the cause of the hypertension and assessment of the patient every three months post-surgery should be essential to monitor for any complications. A therapist should be included as a guideline after gastric surgery to allow for a rapport to developed and a trust relationship as many people do not tell their primary care physicians of their alcohol intake. According to Freire, 20% of gastric bypass patients develop alcoholism (2020). Education is important and with education, patients feel empowered and are more compliant with treatment so this should have been provided at every doctor visit verbally and in writing (Rosental, 2021). Unfortunately, these interventions were too late for this patient.ReferencesAbou Assi, R., Abdulbaqi, I. M., & Siok Yee, C. (2021). The evaluation of drug delivery nanocarrierdevelopment and pharmacological briefing for metabolic-associated fatty liver disease (MAFLD):An update. Pharmaceuticals, 14(3), 215.Briegleb, M., & Hanak, C. (2020). Gastric bypass and alcohol use: A literature review. PsychiatriaDanubina, 32(suppl. 1), 176-179.Chrøis, K. M., Larsen, S., Pedersen, J. S., Rygg, M. O., Boilsen, A. E. B., Bendtsen, F., & Dela, F. (2020).Acetaminophen toxicity induces mitochondrial complex I inhibition in human liver tissue. Basic &clinical pharmacology & toxicology, 126(1), 86-91.Freire, C. C., Zanella, M. T., Arasaki, C. H., Segal, A., & Carneiro, G. (2020). Binge eating disorder is notpredictive of alcohol abuse disorders in long-term follow-up period after Roux-en-Y gastric bypasssurgery. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 25(3), 637-642.Lorico, S., & Colton, B. (2020). Medication management and pharmacokinetic changes after bariatricsurgery. Canadian Family Physician, 66(6), 409-416.Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practicenurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.Santos, J. G. D., & Cruz, M. S. (2016). Alcoholism following bariatric surgery: case report. JournalBrasileiro de Psiquiatria, 65, 340-343.HOW WOULD YOU RESPOND TO THIS SCENARIO????Health Science Science Nursing NURS 6521
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