Medication: A Case Study

Medication:

Tylenol #3 1-2 tabs PO q4h PO prn
Docusate 100 mg PO BID prn

Rationale:

Received 400mg ibuprofen 3 hours ago and her current level of pain is 7/10. I am choosing to give her Tylenol #3 to control the intense pain she is experiencing from the episiotomy and third-degree laceration and intense labour. This medication is appropriate because she reported experiencing a lot of pain since delivery. The length of time that is appropriate for her to take this medication is solely based upon continuous assessments of her pain between doses. Continuous pain assessment will determine how long she will take this medication as a major concern is the crossing over of codeine, acetaminophen and caffeine into the breast milk (Chow, 2013).

Educating her about adverse effects of diarrhea, cramping, headaches, fatigue and loss of fluid and electrolyte imbalances. I am encouraging hydration and will continually be assessing her for signs of dehydration and do laboratory tests to determine electrolyte levels if needed. Also, comparing these assessments with baseline findings of stool color, consistency and frequency (Karch, 2013).

5. Given in an upright position and stay with her to make sure she takes them

6. Preform hand hygiene again

7. Document: record what I gave the amount I gave, and why it was given

- Gave patient 2 tabs of Tylenol #3 PO 0 (then q4 hours PO prn)
- Gave patient 100mg of Docusate PO (bid). Timing of this medication is 30 minutes after the Tylenol 3 as a caution to this medication is to wait 30 minutes between medications.

8. Check back in with the patient 30 minutes after receiving the medication to assess if the desired effects of the medication are effective and to assess for adverse effects.

Tylenol #3
Docusate
Adverse effects
Respiratory depressions with apnea, orthostatic hypotension, nausea, vomiting, constipation, light headedness, dizziness, anxiety (Karch, 2013).
Diarrhea, abdominal cramping, nausea. Dizziness, headache, fatigue, weakness, loss of fluid, electrolyte

The non narcotic pain reliever is acetaminophen. The codeine affects the central nervous system affecting the way the brain interprets pain. The desired effects of the codeine property are to decrease the high levels of pain she has been experiencing since giving birth so that she can be comfortable enough to sleep to allow her body to rest and heal. Acetaminophen contains antipyretic and analgesic properties that help to increase the internal temperature to induce sweating. This helps to rid the body of toxins or infection. Risk for infections during the birthing process is something that is of concern. Things that increase likelihood of infection: frequent vaginal