Medication history

Name: _Sydonie Stock____________________________

Why: To assess the patients knowledge and understanding of the medications she is taking
Where: At B. A.s house
Who: _____B. A._____78_____Female_________participating
How:
Introduction: I explained the homework assignment and asked if she would let me ask her some
questions about her medications
Review past medical history
o She has a clotting problem, cant remember what it is called, but it is a genetic problem;
Hx of blood clots; Bilateral hip replacement in 2009; Hx of high blood pressure; Hx of mild
high cholesterol
List medications (scheduled and prn: OTC, R
x
, illicit, herbal, etc.)
Name: Coumadin
o Dose: 5mg
o Frequency: QHS
o Reason for use: Hx 2 blood clots
o How long taken: 4 or 5 years
o Pharmacokinetics: makes my blood thinner because I clot too easily
o Drug interactions: interacts with aspirin, check with the doctor before taking anything,
even just a cough drop - she doesnt take anything but her prescriptions, not even
Tylenol.

Name: calls it Cholesterol pill, Simvastatin
o Dose: 40mg
o Frequency: QHS
o Reason for use: Doesnt know why, her cholesterol wasnt that high, then it normalized
and her doctor wont take her off it
o How long taken: 2 or 3 years
o Pharmacokinetics: no. (I explained how I thought it worked, but would have like to have
looked it up in our notes)
o Drug interactions: no. (has the drug info inserts saved in case she wants to look them up)

Name: Vitamin D
o Dose: 1000mg
o Frequency: Every other day
o Reason for use: 2 hip replacements
o How long taken: 1 years
o Pharmacokinetics: no (I explained Vitamin D helps the body absorb calcium from the diet
and her supplementary pills, so its not being taken from her bones)
o Drug interactions: no

Name: Calcium
o Dose: 600mg Chewable
o Frequency: Daily (lunch time)
o Reason for use: bilateral hip replacements
o How long taken: 3 years
o Pharmacokinetics: makes my bones healthier (I explained it also helps with cell
metabolism)
o Drug interactions: calcium will inhibit zinc

Name: hydrochlorothiazide
o Dose: 25mg
o Frequency: QAM
o Reason for use: hereditary high blood pressure
o How long taken: 5 years
o Pharmacokinetics: getting rid of the fluid, so I dont hold fluid (I explained how that affects
blood pressure by getting rid of some of the volume within the blood vessels)
o Drug interactions: doesnt know of any

Name: Losinopril
o Dose: 40mg
o Frequency: QAM
o Reason for use: hereditary high blood pressure
o How long taken: 5 years
o Pharmacokinetics: bringing my blood pressure down (looked it up in her info sheet - ace
inhibitor, relaxes blood vessels)
o Drug interactions: no. has read on a cough drop label to check with the doctor if youre on
high blood pressure medicine - threw it away the cough drops because she didnt want to
bother with the doctor

Name: Omeprazole (prilosec)
o Dose: 20mg
o Frequency: QHS
o Reason for use: has always had a touchy stomach, gets heart burn every once in a
while if she doesnt take it. Heart burn at night, wakes up at 12:30 and has to walk around
to burp (I explained the process of acid reflux because she didnt know why they called it
that when only gas was coming back up, not food)
o How long taken: 6 or 7 years
o Pharmacokinetics: the acid thing in my stomach to keep from getting heart burn (was
concerned that taking it too long would damage the acid production in her stomach, but I
explained that her kidneys make her pee out the drug, so it doesnt build up in her
stomach)
o Drug interactions: no

Identify concerns or barriers (use Gordons functional health patterns)
o Have you had problems that can be attributed to the medications? Give example(s).
Gordons Functional Health Pattern: Health-seeking behaviors r/t following the
prescribed medication guidelines
She cant have grapefruit in the morning like she used to (Simvastatin).
She shouldnt have anything high in Vitamin K (clotting factor). She recently
learned that cranberries are high in Vitamin K.
Gets sunburned very easily, even through clothes. She doesnt know the cause,
if it is because of a drug, she thinks maybe Coumadin. She will ask doctor during
her April appointment.
o Are you able to safely take medications as prescribed? Give example(s).
Gordons Functional Health Pattern: Effective therapeutic regimen management
Yes, she trusts the doctor to prescribe the medications to be safe with each other
B. A. just recently changed her insurance provider from Humana to Priority
Health. Humana used to pay for all of her medication, but Priority Health does
not, so will have to keep track of her finances to see if it is worth the switch.
She made the switch because Spectrum Health does not accept
Humana insurance, so she would have to go to Muskegon for all her
testing instead of going to the closer hospital in Fremont.
o What information or instructions were you given when the medications were first
prescribed?
Gordons Functional Health Pattern: Readiness for enhanced therapeutic
regimen management
When to take it and what it was for, how much to take, how often. No special
instructions
o Do you think the medications are doing what they were prescribed to do? Give
example(s).
Gordons Functional Health Pattern: Effective therapeutic regimen management
Yes. Test results come back better. Stomach feels better, but otherwise she
doesnt feel any different
o Does anyone else help you take your medications?
Gordons Functional Health Pattern: Effective therapeutic regimen management
No, she is self-reliant.

Wrap up:

Reflection (~300 words)
o Identify questions that could have been asked as well as patient teaching that could have
been conducted if you had more knowledge about the medications.
o I wasnt too clear on how the Statin drugs work. How I explained it was the drug
helps the body kick out the bad fats and cholesterol and help raise the good fats.
While this explanation worked for a layman like B. A. I would have like to study
the Statin drugs more closely so I could give a better explanation.
o Identify strategies you would offer to reduce medication errors or incidents.
o I would suggest looking into the drug to drug interactions when she is prescribed
something new because the doctor is not always thinking about the drugs she is
already taking - only what she needs now. B. A. trusts her physician to remember
or look up all the drugs she is currently taking, but as a budding nurse, I know
that is not always what happens.
o Identify aspects of a medication history you would change in the future (gather more or
less information).
o I would get more detailed information about her medical history. I didnt explain
what I needed for that question very well; she just went into why she takes her
drugs. I think she did that because when I introduced what my homework
assignment was, I told her it was discussing her medications and why she takes
them.
o Identify what you learned doing this assignment.
o Patients, especially elderly, will trust the doctor to make the right decisions and
will not question their orders. Younger patients are more willing to research the
condition or medication and come back with questions, but B. A. did not. She
questioned why she was still on her cholesterol pill even though her cholesterol
levels were back to normal. Her physician told her to keep taking the pill because
it wouldnt hurt her, but she didnt want to take it if she didnt have to. So when I
explained that the medication was helping her body keep the cholesterol levels
low, she was more willing to continue taking the pills.