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Zorluk: Çok zorPharmacological Therapies

A 72-year-old client diagnosed with bipolar disorder is maintained on oral lithium carbonate. The primary care provider recently added an oral prescription of hydrochlorothiazide to manage the client's newly diagnosed hypertension. Upon evaluating the morning laboratory data, the practical nurse notes a serum lithium level of 0.9 mEq/L0.9\text{ mEq/L} and a serum sodium level of 128 mEq/L128\text{ mEq/L}. The client reports a mild headache, nausea, and increased lethargy. Which action should the practical nurse take first?

  1. Hold both scheduled medications and promptly notify the registered nurse regarding the client's laboratory results and physical symptoms.Cevap
  2. B
    Administer the medications as prescribed and reassure the client that mild lethargy is a normal age-related change when starting a new antihypertensive.
  3. C
    Administer the lithium carbonate because the level is within the therapeutic range, but hold the hydrochlorothiazide due to the hyponatremia.
  4. D
    Confirm the client's identity using their spoken name and room number, then administer both medications to maintain the therapeutic lithium level.

Cevap

The practical nurse must withhold both medications and notify the registered nurse immediately due to the high risk of severe lithium toxicity caused by hyponatremia.
The correct action is to hold both medications and notify the registered nurse. The client's sodium level is critically low (128 mEq/L128\text{ mEq/L}). Because the kidneys process lithium and sodium similarly, low sodium levels trigger the kidneys to aggressively reabsorb lithium to compensate. Administering more lithium in the presence of hyponatremia—especially alongside a sodium-depleting thiazide diuretic like hydrochlorothiazide—will rapidly lead to life-threatening lithium toxicity, despite the currently normal lithium level. The client's headache, nausea, and lethargy are early indicators of this dangerous physiological shift.

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1
Analyze the laboratory values in the context of the prescribed medications.
The lithium level (0.9 mEq/L0.9\text{ mEq/L}) is therapeutic (normal: 0.6−1.2 mEq/L0.6-1.2\text{ mEq/L}), but the sodium level (128 mEq/L128\text{ mEq/L}) indicates significant hyponatremia (normal: 135−145 mEq/L135-145\text{ mEq/L}).
Identifying abnormal baseline laboratory data is critical before administering medications that directly affect fluid and electrolyte balance.
2
Evaluate the pharmacological interaction between hydrochlorothiazide and lithium carbonate.
Hydrochlorothiazide is a thiazide diuretic that causes sodium loss. When serum sodium is depleted, the kidneys reabsorb lithium instead of excreting it, which rapidly leads to lithium toxicity.
Understanding complex drug interactions and renal pharmacokinetics prevents the administration of harmful medication combinations.
3
Correlate the client's physical symptoms with the clinical laboratory data.
The client's mild headache, nausea, and increased lethargy are early neurological signs of both hyponatremia and impending lithium toxicity.
Connecting physical symptoms to laboratory abnormalities confirms a deteriorating clinical status that requires immediate intervention.
4
Determine the safest action within the practical nursing scope of practice.
The safest and most appropriate action is to withhold both the hydrochlorothiazide and the lithium carbonate and immediately report all findings to the supervising registered nurse.
The practical nurse must protect the client from harm by withholding contraindicated medications and promptly escalating critical changes in condition.

Anahtar Kavram

Lithium toxicity risk is significantly increased by hyponatremia, often caused by sodium-depleting medications like thiazide diuretics; the practical nurse must recognize this interaction, withhold the medications, and report to the registered nurse.
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