Situation: The 90-year-old woman was accompanied by her daughter with complaint of left sided chest, which did not respond to nitroglycerin. Upon reaching the hospital the patient denied having any chest pains.
Background
The patient has had several illnesses in her life time which include transient ischemic attack in 2012, hypertension, congestive heart failure, thyroid disease, renal disease, type 2 diabetes, seizure and dental anomalies. The patient has been operated several times including cardiac pacemaker placement (2010), appendectomy (1966), hysterectomy (1971), toe amputation (2007), eye surgery (2010), nephroctomy (2013) and ureteral stent exchange (2013). He has a known allergy of Lipitor (atorvastatin)
Diagnostic tests results:
EKG: rhythm paced at 80. Chest X-ray shows cardiomegaly, FBC shows mild anemia with a hemocrit of 33. Urinalysis shows elevated serum creatinine of 1.81mg/dl.
Head to toe assessment
Neurological: the patient has normocephalic and atraumatic, ear and eyes are all present with no discharge or any notable abnormality. During the assessment, the patient was fully awake and alert. Glasgow Coma Scale score was 14. The patient has episodic confusion evidenced by lack of insight and orientation.
Cardiovascular: vital signs: – BP 141/81, Pulse 81, SpO2 100%. Her conjunctiva and tongue exhibit mild pallor. She has a venous access on the left cubital fossa. The S1 and S2 were heard on auscultation and no abnormal sounds were heard.
Respiratory: the chest cage move symmetrically during respiration, the respiratory rate was 18/breaths per minute. On auscultation the air flow turbulently and no adventurous sounds were heard.
Gastrointestinal: On observation, the abdomen is not distended. Onauscultation, the bowel sounds were audible. On palpation, no rebound tenderness and no guarding were exhibited. On percussion, the abdomen was tympanic except for the hypochondriac regions, which were dull.
Genitourinary: patient has renal insufficiency
Skin: In general, patient has dry and warm skin. The lower extremities have erythema bilaterally with some skin tears close to her ankles bilaterally.
Musculoskeletal: the patient has bilateral pedal edema
Medications
Home medication
The patient has been taking several medications at home to manage her chronic illnesses such as diabetes and hypertension. The daughter who is the primary care giver of the patient demonstrated outstanding understanding of her mother’s conditions, her medications, the side effects of the drugs. The patient on the other hand is confused and cannot be left to administer the drugs on her own.
Current medications:
The patient is taking oral acetaminophen 650mg whenever necessary depending on temperature (> 380 C) and pain (mild pain) up to a maximum dosage of 4000mg in 24 hours. Other oral medication include allopurinol 200mg once daily, ascorbic acid 1500mg daily, aspirin 81mg daily, carvedilol 3.125mg twice daily, and clopldogrel 75 mg daily. The patient is also on Simvastatin 40mg tablets, pantoprazole 40 mg daily, and ondansetron 4 mg whenever necessary depending on vomiting and nausea episodes. The patient is also on nitroglycerin 0.4mg sublingually every five minutes whenever the patient has chest pains.
Nursing diagnoses:
Acute pain related to tissue ischemic secondary to tissue inflammation as evidenced by patient verbal reporting and face grimace.
Ineffective tissue perfusion related decreased blood flow as evidenced by pallor in the tongue, dry skin and pallor of the conjunctiva.
Knowledge deficit about the treatment regime related to inaccurate information as evidenced by varying data between the daughter and the patient.
Impaired verbal communication related to physiological and psychological changes as evidenced episodic confusion and inappropriate verbal response.
Risk of infection related to ineffective tissue integrity as evidenced by broken skin in the lower extremities.
Recommendations:
The patient should be reviewed by a psychiatric to manage confusion. The nursing management for the patient should incorporate patient’s daughter to ensure adherence to the care.
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