Question

Mrs. Baker is a 79-year old female admitted to your unit with a complaint of anorexia, fatigue, pain and swelling of the left lower extremity. She was admitted with a diagnosis of cellulitis of the right lower extremity with a wound infection on her right heel. She is on bed rest. She has a history of Diabetes, Hypertension, Afib and CAD. She is 5’5”, weighs 102 lbs.

Mrs. Baker is awake, alert, and oriented x3. Heart rate is regular at 59; lungs are decreased bilaterally in the bases; O2 sat is 90% on room air. She has positive bowel sounds, positive pedal pulses, and bilateral edema of the lower legs. She is voiding frequent small amounts of clear yellow urine in the bedpan. She has an IV of 0.9% NSS infusing at 125ml/hr in the R forearm that is intact and patent. She has a 3cm x 4cm open wound on her right heel.

Vital signs on admission were T: 39.1, HR: 84 and regular, RR: 24; BP 182/98. She c/o of pain in the right lower extremity 8/10 and was medicated with Oxycodone. Her appetite has been fair at best. The blood sugar at 0730 was 168 and she received 10 units of Novolog insulin. She ate 10% of breakfast. She was sent to Nuclear Medicine for a CAT Scan with Contrast of her right lower extremity.

Mrs. Baker tells you that she is on so much medication that she sometimes does not refill the medications because they are too expensive. She is on a fixed income and has to pay her bills and still eat.

Social History: Obtained from the Home Health Nurse- who visits Mrs. Baker weekly

Mrs. Baker is divorced. She has a 97 year old father who lives in a nursing home 400 miles away and a 59 year old estranged daughter who lives 90 miles away. Mrs. Baker also has a 23 year old granddaughter who lives in the home with her but is in and out on a consistent basis. Her granddaughter does not work and often asks Mrs. Baker for spending money. The granddaughter becomes very hostile and angry when her grandmother does not “lend her money”. Mrs. Baker has told several people that her granddaughter serves as her care giver. She owns her home in a lower middle class neighborhood but it is in very poor condition. She eats 2 meals a day, smokes 3 packs of cigarettes and drinks a pint of alcohol weekly. She rarely sees or communicates with her neighbors; occasionally will answer her telephone or doorbell. She realizes that she cannot fully maintain her home or herself independently but refuses in- home services and placement. She has a protective services case worker who has tried to arrange help, but Mrs. Baker refuses all attempts. She does not respond to her physician’s request to keep her appointments. She also refuses to discuss her finances with anyone.

Meds: Daily

Glipizide 5 mg po bid, Metformin 1000mg po bid, Novolog 10 units sq. tid with meals, Novolog sliding scale, HCTZ 12.5 mg po bid, Lisinopril 20 mg po bid, Protonix 40 mg po daily, Lovenox 40 mg SQ daily, Magnesium Oxide 400 mg po daily, Levemir 40 units SQ qhs, Potassium Chloride 20meq po daily, Digoxin 0.125 mgs po daily, Metoprolol 25 mgs.po daily, ASA 81 mgs. daily, Vascepa 2 grams po. Bid, Aricept 10 mgs. po hs, Coumadin per orders.

Meds: PRN-Oxycodone/Acetaminophen 5/325 mgs po q4h prn pain, Hydralazine 20 mg IV for SBP> 160 q6h prn

Lab Results:

RBC 4.2                                     Platelets- 106,000                                             CL- 107mEq/L-

WBC- 13.2                                 INR 2.2-                                                            Mag- 1.2 mEq-

HGB- 10g/dl                                K+ 2.9mEq/L                                                      Hgb A1C -10%

HCT- 33.4%                                NA- 140-                                                          FBS-200mg/Dl

I. Questions to be answered for Medication Administration: Use Unbound Medicine-Davis’s Drug Guide for Nurses

1.      Why is the patient taking each daily medication? - do not list the action of the meds.

Glipizide, Metformin, Novolog, Levemir-                               Lovenox-

HCTZ, Lisinopril, Metoprolol –                                                        Mag Oxide-

Potassium Chloride-

Protonix-

Digoxin

Vascepa-

2.Based on your assessment of the patient are there any medication(s) that she should be taking which are not currently ordered? If so, which class of medication should be ordered and why (you do not have to give the name of a specific medication).

Are there any medications that should be held?

3.      What combination of medications ordered for Mrs. Baker poses the greatest risk for the patient? Explain why.

         

4.      Which medication should be held prior to the CAT Scan? Explain why the med should be held and how long this medication should be held.

II. Questions to be answered for Lab Tests Results:

Explain why the labs were performed- you may group related labs together. i.e. Hgb & Hct

What do the lab results indicate?

NURSING DIAGNOSIS:

Problem List	A. Choose 4 Priority Problems for the Concept Map and state in Nursing Diagnosis Format. B. From the 4 Priority Problems; Choose 2 Priority Nursing Diagnosis, of which one must be an actual problem. C. Expand on each of the 2 priority problems-include correct format, goal and 5 interventions. D. Goals must be measurable, short-term and achievable within 48 hours.
List all highlighted/underlined in the assessment

List 3 areas of teaching for the patient. Explain in detail what you will teach the patient/ significant other concerning her diagnosis.

Other questions to consider:

1.     Are there any ethical/moral obligations in caring for Mrs. Baker?

2.     What is your emotional response to the thought of caring for an older person who has been mistreated?

3.     Identify actions that can help relieve stress in family caregivers.

Answer 1

The following are the answers to the questions under section I

1)The following are the reasons why she take these medications daily.

• Glipizide and metformin are the oral hypoglycemic drugs and Novolog,Letemir are type of insulins. These are used to reduce her blood sugar levels.(For Diabetes)
• HCTZ(Hydrochlorthiazide), lisinopril and metoprolol are anti hypertensive drugs used to control her high blood pressure.
• Potassium chloride is used to correct hypokalemia(low K+ level)
• Protonix is used to prevent gastric ulcer or to reduce heart burn.
• Digoxin is used to prevent atrial fibrillation and maintain sinus rhythm.
• Vascepa is used for lowering trigylceride levels.
• Lovenox is an anticoagulant used for DVT prophylaxis.
• Magnesium oxide is used as supplement and also to treat indigestion.

2)Based on the assessment, antibiotics(broad spectrum) should be ordered because the diagnosis is made as cellulitis and wound infection.Also, the patient has diabetes.So, if any infection left untreated will cause sepsis and multi organ failure.

3)Taking Lovenox(LMW Heparin), ASA(Aspirin), Coumadin(warfarin) together put the patient at greater risk for bleeding.This is because all three agents prevent clot formation by reducing platelet aggregation, so they tend to bleed for longer time than usual.

4)Diuretics like HCTZ ,ACE Inhibitors like Lisinopril should be held prior to CAT scan, because contrast is given in CAT scan. Using all these drugs will cause acute kidney failure.