Medication History

Client Name (initials) _CF________________________

Age _______55________________________________
Occupation ____RN_____________________________
Allergies (list all with reaction if known)
____NKA____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____
Medical History (for each condition, please describe whether it is past, acute,
recurring, or chronic) _____Chronic heart burn, chronic constipation, anemia, HTN
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________________
Surgical History
______Hysterectomy in 2013
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Prescribed Medications
Medication

Taken for (in client words)

Lisinopril
Prilosec
Zantac PRN 160mg
Colace

HTN
Acid Reflux
Heart burn
Constipation

OTC Medication/Supplements NOTE: for this section, it is often useful to prompt the
client by asking them if they take any medications such as: cough/cold, allergy, acid
reflux/heartburn, anti-diarrheals, vitamins, sleep aids, diet aids, topical medications,
etc.
Medication/Vitamin/Supplement
Multivitamin with iron

Taken for (in client words)

Supplement

Any dietary restrictions? (Describe)

_________None______________________________________________________________________
_____________________________________________________________________________________
______
Smoking, other tobacco use (What type, how much daily, how long)
__Former smoker for 15 years.
__________________________________________________________________________________
Alcohol use (type, frequency) ______One_glass of wine, daily, with dinner
______________________________________________________________________________
Drugs of abuse (Marijuana, cocaine, methamphetamine, heroin, make sure to ask
specifically about medical marijuana as well) now or in the past year? ___
None
_____________________________________________________________________________________
_________________________________________________________________________________
Does client take full responsibility for medication administration (including for
picking up medications from pharmacy) or does someone else assist in process? If
so, who __
Client_ picks up own medications independently.
_____________________________________________________________________________________
__________________________________________________________________________________
What time(s) of day does client take medication?_______Morning,_zantac PRN before
meals _____________________________________
What does the client do when a dose of medication is missed? _______Client_states
to continue the next day medications as normal
_____________________________________________________________________________________
_____________________________________________________________________________
Does the client ever not take medications as prescribed (phrase this question to
normalize the behavior, for example some clients do not always take their
medication exactly as prescribed, for instance, some clients who take blood
pressure pills do not take their pill or only take a half pill if their blood pressure is
below 130/80, do you ever modify your medication dose or schedule like that?)
_____No_____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____
How/where are medications stored in the home? ______Medications are stored in the
bathroom medicine cabinet

_____________________________________________________________________________________
_______________________________________________________________________________
Are there any young children in the home or who come to visit? Teenagers?
______No____________________________________________________________________________
_____________________________________________________________________________________
___
Does the client ever take someone elses medication (normalize this again, for
example: some clients may take a friend or family members medication if they run
out of their own if they know the medication is for the same condition, like taking a
spouses blood pressure pill)?
______No____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___
Does the client ever share his/her medication with anyone else?
______No____________________________________________________________________________
_____________________________________________________________________________________
___
Does the client have any concerns about current medications?
________No__________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___
Has the client ever had a bad reaction or response to a prescription, OTC, or
supplement in the past?
___No_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
___

Reflection Questions

1. Did the client understand the purpose for all medications being taken (and
was that purpose correct)?
The client had good understanding for all of the medications that she was
taking.
2. Were there any conditions that the client did not take medication for? Were
there any medications the client took which did not seem to match up to any
conditions?
All of the medications matched up with conditions that she was taking them
for. There were not any medical conditions that appered to be left untreated.
3. For each condition and medication: describe the medication action and
expected outcome on the disease/condition process (for example: client with
hypertension taking hydrochlorothiazide: what is the mechanism of action?
How does this lower the blood pressure?)
Client with anemia taking a multivitamin with iron acts a dietary supplement
for a lack of nutrients that are consumed in clients diet. The iron helps
maintain normal ferritin and hemoglobin levels.
Client with HTN is taking Lisinopril an ace inhibitor, mechanism of action is
blocking the conversion a angiotensin I to the vasoconstrictor angiotensin II.
Ace inhibitors also prevent the degradation of bradykinin and other
vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels
and decrease aldosterone levels. The therapeutic effects are lowering the BP.
Client with acid reflux is taking Prilosec. Mechanism of action : Binds to an
enzyme on the gastric parietal cells in the presence of acidic gastric pH,
preventing the final transport of hydrogen ions into the gastric lumen.
Therapeutic effects are diminished accumulation of acid in the gastric lumen
with lessened gastroesophageal reflux.
Client with heart burn is taking Zantac. Mechanism of action: Inhibits the
action of histamine at the H2 receptor site located primarily in gastric parietal
cells, resulting in inhibition of gastric acid secretion. Therapeutic effects:
Decreased symptoms of gastroesophageal reflux, decreased secretion of
gastric acid.
Client is taking Colace for constipation. Mechanism of action: promotes
incorporation of water into stool, resulting in softer fecal mass. May also
promote electrolyte and water secretion into the colon. Therapeutic effect:
Softening and passage of stool.

4.

Does the client have any conditions or personal characteristics which are
significant to medication administration (e.g. geriatric patient, patient with
poor renal function, patient who cannot swallow pills, patient with impaired
memory which may impact medication-taking, etc.)? Describe.
The client does not have any conditions significant to medications
administration.
5. Imagine that you are a nurse admitting this client to the hospital. Is there
anything on this patients history that you want to clarify with the patients
primary care provider (or prescribing specialist)? Any potential interactions
you noticed? Do you have any concerns about the clients medication
list/administration pattern/adherence to regimen, etc?
The only think that stuck out to me is that the patient is taking zantac and
Prilosec for acid reflux/heart burn. I know some people have altered their
diets and eliminated antacids from their medication regime. This might be an
opportunity for patient education.

6. Imagine that you are discharging this same patient from the hospital with a
new prescription for an expensive medication and the patient discloses to you
that he/she cannot afford the new medication, what will you do?
Almost every pharmaceutical company has patient assistance programs to
help people who cant afford their brand name drugs. There are resources to
make prescriptions affordable to clients while in the hospital. I would discuss
with the hospitals social worker or case manager and assess what options
would be available given the clients situation.