Patient Centered CarePatient Centered Care

H.A

76 y/o white femaleAllergies: NKDA, NKFA

Admitted to MSU on 6/27/15 for LEFT HIP FRACTUREHospital day: 3Post-op day: 1

PMHx: HTN, BLE DVT, splenic vein thrombosis, glaucoma, urinary retention, UTIs, acute kidney injury in the past, Morbitz type I AV block, significant blood loss anemia ? r/t nonbleeding rectal mucosa ulceration in Nov 2014, PE in Nov 2014 , history of mechanical fall with acute compression of L1Psych Hx: Bipolar affective disorder, dementiaSocial Hx: non smoker, no alcohol consumption, one son, separated but lives with husband (primary care give)

Meet the patient

Hospital day: 3, Post-op day: 1 Comes from Summit Elder Care 2days/week Oriented to person only and confused at baseline Returned from surgery @ 1700 (June 29), sleepy and lethargic but easily

arousable. @ 0030 agitated, pulled out IV line, POX senor from finger, attempted to

“jump out” of bed several times, and tried to pull the catheter out. 0.5 mg Haldol x1 dose was given.

H/H: 6.5/19.4. MD notified. Order: 3 units of PRBC Heparin drip D/C @0530. Now SCDs only. LS diminished. O2sat 94% on RA NSR D5NS @ 80ml/hr

Shift report, June 30

Pt ambulating barefooted to the bathroom Entangled with the floor rug and had a fall Found on the floor by the husband Brought to ED for complains of left hip pain No report of loss of consciousness or head

trauma

The Injury

Neuro: A+O x1, oriented to person only, confused. CV: No c/o chest pain. Skin pale, warm & dry, cap refill <

3sec. HR 68 irregular. BP 111/68. No edema, +PP bilat. Tele: NSR.

Resp: RR 18, regular, non-labored, no SOB noted. O2sat 95% on RA. LS diminished but clear bilaterally throughout.

GI: Abd soft, non-tender, non-distended. +BS x4Q. 2 small BMs

GU: Foley catheter, clear, yellow urine. Output: 240 ml/shift MSK: slight muscle atrophy noted, LLE weakness noted. INTEG: Skin intact, warm and dry. Incision sites intact. Left

hip middle dsg w/ serosanguineous drainage. Dsg changed. Dsgs clean, intact, and dry.

Assesment

Tylenol 5mg PO q6h PRN Calcium 600+ D3 1 tablet PO daily Aspirin 81 mg PO daily MiraLAx PO daily PRN Potassium chloride ER 20 mg PO daily Depakote ER 500 mg PO BID Aricept 5 mg PO daily Effexor XR 75 mg PO daily Lovenox 100 mg injection 1.5 mg/kg subcutaneously daily (slightly higher

dose) Olanzapine 10 mg PO daily @ night Chlorthalidone 25 mg PO daily Lorazepam 0.5 mg three times/day meTOPROLOL 12.5 mg PO BID

Home Medications

Valproates (Depakote) ER 500 mg PO BID (Mood Stabilizer)

Dizziness, sedation, confusion, visual disturbances, tremor, ataxia Donepezil (Aricept) 5 mg PO daily (dementia/AD)

Dizziness, drowsiness, fatigue, syncope, frequent urination Venlafaxine (Effexor) XR 75 mg PO daily (depression/anxiety)

Dizziness, weakness, urinary frequency, urinary retention Olanzapine (Zyprexa)10 mg PO daily @ night (Mood stabilizer)

Dizziness, agitation, delirium, restlessness, sedation, speech imparment, tardive dyskinesia , urinary incontinence

Chlorthalidone 25 mg PO daily (HTN) Dizziness, drowsiness, lethargy, weakness, hypotension, hypokalemia

Lorazepam (Ativan) 0.5 mg three times/day (Anxiety) Dizziness, drowsiness, lethargy, weakness

meTOPROLOL 12.5 mg PO BID (HTN) Dizziness, drowsiness, lethargy, weakness, hypotension, urinary frequency

Medications: A contributing factor?

Diagnostics

3 units of PRBC Potassium chloride 40mEq PO q4h x2 doses Potassium chloride 40 mEq IV once (infuse 10

mEq over 1 hr) Magnesium sulfate 1 g in D5W IV once D5NS @ 80 ml/hr Flurosemide (Lasix) 20 mg IV push one time

after the second unit of PRBC.

Orders

Acute Delirium Risk for Falls Polypharmacy Self care deficit Care giver needs

Elder care considerations

1. Fluid and Electrolyte imbalance r/t blood loss

secondary to surgical procedure. 2. Risk for injury r/t delirium, confusion,

wandering, and incontinence. 3. Self-care deficit (i.e. feeding, ADL

performance) r/t cognitive and physical impairment.

4. Caregiver role strain r/t progression of chronic debilitating disease process

Nursing Diagnosis

NCLEX QUESTIONS

A. Stop the transfusionB. Send the blood bag and IV tubing to the

blood bankC. Maintain an IV infusion with 0.9% sodium

chlorideD. Elevate the client’s feetE. Obtain blood culture

1. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply)

A. The first action is to stop transfusionB. The blood bag and IV tubing are send to the

lab for analysisC. 0.9% sodium chloride should be administered

through new IV tubing

Answer 1

A. “This medication should increase my wife’s

appetite.”B. “This medication should help my wife sleep

better.”C. “This medication should help my wife’s daily

function.”D. “This medication should increase my wife’s

energy level.”

2. A nurse is providing teaching to the partner of an older adult client who had dementia and has a new prescription for donepezil (Aricept). Which of the following statement by the partner indicates the teaching is effective?

C. Donepezil helps slow the progression of dementia/AD and may help improve behavior and daily functions.

Answer 2

A. Remove floor rugs. B. Have door locks that are easily opened.C. Provide increased lighting in stairwells.D. Install handrails in the bathroom.E. Place the mattress on the floor.

3. A nurse is making a home visit to a client who has dementia. The client’s husband states that the client is often disoriented to time and place, is unsteady on her feet, and has a history of wandering. Which of the following safety measures should the nurse review with him? (Select all that apply)

A, C, D, E

Answer 3