Transcript Geriatric Case Study

Patient Centered Care
Meet the patient
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H.A
76 y/o white female
Allergies: NKDA, NKFA
Admitted to MSU on 6/27/15 for LEFT HIP FRACTURE
Hospital day: 3
Post-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 L1
Psych Hx: Bipolar affective disorder, dementia
Social Hx: non smoker, no alcohol consumption, one son,
separated but lives with husband (primary care give)
Shift report, June 30
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 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
The Injury
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 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
Assesment
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 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.
Home Medications
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Tylenol 5mg PO q6h PRN
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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
Medications: A contributing
factor?
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 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
Diagnostics
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Labs (on admission, 6/27):
Labs 6/30 (post-op day 1)
WBC: 8.5
RBC: 3.94
HGB: 12.7
HCT: 37.7
PLT: 157
Na: 140
K: 3.9
Cl: 106
Ca: 9.1
Mg: 1.8
BUN: 28
Creat: 0.99
WBC: 5.7
RBC: 2.03
HGB: 6.5
HCT: 19.4
PLT:136
Na: 142
K: 3.1
Cl: 109
Ca: 7.8
Mg: 1.6
BUN 16
Creat: 0.89
Orders
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 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.
Elder care considerations
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 Acute Delirium
 Risk for Falls
 Polypharmacy
 Self care deficit
 Care giver needs
Nursing Diagnosis
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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
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NCLEX QUESTIONS
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)
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A.
B.
C.
D.
E.
Stop the transfusion
Send the blood bag and IV tubing to the blood bank
Maintain an IV infusion with 0.9% sodium chloride
Elevate the client’s feet
Obtain blood culture
Answer 1
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A. The first action is to stop transfusion
B. The blood bag and IV tubing are send to the lab for
analysis
C. 0.9% sodium chloride should be administered
through new IV tubing
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?
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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.”
Answer 2
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C. Donepezil helps slow the progression of
dementia/AD and may help improve behavior and
daily functions.
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)
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A.
B.
C.
D.
E.
Remove floor rugs.
Have door locks that are easily opened.
Provide increased lighting in stairwells.
Install handrails in the bathroom.
Place the mattress on the floor.
Answer 3
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A, C, D, E