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Difficulty: HardPharmacological Therapies

A practical nurse (PN) is reviewing the morning data for an older adult client who takes scheduled oral atorvastatin for hyperlipidemia. Three days ago, the client was started on a course of oral clarithromycin for a respiratory infection. During the morning assessment, the client reports profound, generalized muscle aching. The PN observes that the client's urine in the collection device is dark and tea-colored. The morning laboratory results reveal a blood urea nitrogen (BUN) of 35 mg/dL35\text{ mg/dL} (12.5 mmol/L12.5\text{ mmol/L}) and a serum creatinine of 2.4 mg/dL2.4\text{ mg/dL} (212 \mumol/L212\text{ \mu mol/L}). Which of the following is the priority action for the PN?

  1. Withhold the atorvastatin and clarithromycin, and immediately report the clinical findings and laboratory results to the registered nurse (RN).Answer
  2. B
    Administer the scheduled medications and encourage the client to drink additional fluids to help lower the elevated serum creatinine.
  3. C
    Administer a prescribed PRN analgesic for the muscle pain and reposition the client for comfort, delaying the scheduled medications.
  4. D
    Bypass routine barcode scanning to expedite the administration of the clarithromycin, as treating the acute infection is the priority.

Answer

The priority action is to withhold both the atorvastatin and clarithromycin and immediately escalate the clinical findings and laboratory results to the supervising registered nurse (RN).
The correct action demonstrates an understanding of a severe drug-drug interaction. Clarithromycin inhibits the metabolism of atorvastatin, leading to toxic accumulation. The client's symptoms (muscle pain, dark urine) and laboratory values (elevated BUN and creatinine) indicate rhabdomyolysis and acute kidney injury. Within the PN scope of practice, the immediate priority is to ensure safety by withholding the medications and escalating the critical findings to the RN for medical intervention.

Step-by-Step Solution

1
Analyze the client's medication regimen for potential interactions.
The client is taking atorvastatin (a statin) and clarithromycin (a macrolide antibiotic). Clarithromycin strongly inhibits the CYP3A4 enzyme, which metabolizes atorvastatin. This leads to toxic levels of the statin.
Identifying drug-drug interactions is a critical step before administering any medication.
2
Evaluate the client's clinical symptoms and laboratory findings against known adverse effects.
Severe muscle aching, dark tea-colored urine (myoglobinuria), elevated BUN, and elevated serum creatinine indicate rhabdomyolysis and resulting acute kidney injury.
Recognizing severe adverse reactions ensures the nurse does not administer a medication that will cause further harm.
3
Determine the priority nursing intervention within the practical nurse (PN) scope of practice.
The PN must withhold the offending medications and immediately notify the RN and healthcare provider so that emergent medical interventions can be initiated.
The PN's primary responsibility in an adverse event is to maintain client safety by stopping the harm and escalating to the RN or provider for advanced clinical judgment.

Key Concept

Recognizing severe drug interactions leading to rhabdomyolysis, and executing the PN role to withhold medications and report critical findings.
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Topics

Pharmacological Therapies

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