Question Answered step-by-step Case Study Patient Information Frances Mathis is an 80-year-old… Case Study Patient InformationFrances Mathis is an 80-year-old Caucasian female who lives alone in a small home. Her husband, Bill, passed away a year ago, and she has a dog, Katie, who is especially important to her. Frances has two daughters; Marilyn Amber, 60, lives nearby and is Frances’s primary support system. Her current medical problems include hypertension, glaucoma, osteoarthritis of the knee, stress incontinence, osteoporosis, and hypercholesterolemia.Frances was seen at the clinic for routine examination and medication follow-up three weeks ago. She tells the nurse she takes several anti-hypertensive medications, diuretics, and analgesics. During her assessment, Frances provides vital details to the nurse of how she views her current situation. All information has been charted in Frances’s chart. Frances visits with her doctor, and no changes to her care have been made at this time. Frances will have a follow-up visit in 2 months.Several weeks have passed since the clinic visit, and Frances is now in the hospital with a urinary tract infection and dehydration diagnosis. Her presentation is atypical, and she is confused. Her daughter is at her bed side and the nurse is doing a total assessment on Frances. It now shifts change (7 PM), and you have received a report from the off-going nurse. Frances has been in her room on the medical-surgical unit for six hours. She was in the Emergency Department overnight because there were no available beds on the medical units. Due to her confusion, Frances did not take her medications properly in the days prior to admission, and as a result, her blood pressure is significantly elevated. Frances’s daughter, Marilyn, is at the bedside and is quite concerned about the confusion and elevated blood pressure.Shift Report Time: 7:00 PM: Nurse going off shift providing reportSituation: Frances Mathis, an 80-year-old female brought to the ER by her daughter with confusion.Background: When Frances’s daughter stopped in to see her yesterday evening, she found that she was not making sense or acting right. She brought her to the ER, and a decision was made to admit her, but she remained in the ER all night until a bed became available an hour ago. Mrs. Mathis has a history of hypertension, glaucoma, osteoporosis, arthritis, elevated cholesterol, and stress incontinence. It is unclear whether she has taken her medications properly the past few days; her daughter could not tell from looking at her medication box.Assessment: Frances’s vital signs at 3:30 AM: temperature 99.4, heart rate 96, respirations 14, BP 190/98. She was not oriented to time or place and seemed quite confused even now.Her labs were drawn in the ED. Her lab results show: 12000 WBC’s, an elevated sodium, and a urine specific gravity of 1.050. These findings are leading to some signs of a UTI. Urine culture is being done for further analysis, but the patient had to be cued on several instructions with stand-by assistance. Her primary physician Dr. Lund was notified of her admission and gave orders for new medications and routine home medications. I just gave her PM meds about 15 minutes ago, which were: captopril, metoprolol, furosemide, pilocarpine drops, ciprofloxacin, celecoxib, and atorvastatin before dinner. She says she is not experiencing any pain. Current vital signs temperature 97.4, heart rate 76, respirations 14, BP 170/84.Physician’s OrdersAllergies/Sensitivities: None known 0700 ED OrdersLabs: CBC, Basic Metabolic Panel, Urinalysis, Bathroom privileges with assistance. Samantha Turner MD, ED Team 0800 Transfer to Medical UnitBathroom privileges with assistance.Regular, low-fat diet I & O record every 4 hours Metoprolol 100 mg po every day Atorvastatin 50 mg po daily Pilocarpine, 2% eye, drops, each eye instill 2 drops BIDAleve 200 mg po prn pain every 6 hoursCiprofloxacin 250 mg po every 12 hours Acetaminophen 325 mg PO every 6 hours prn fever Eric Lund, MDList at least two desired positive outcomes for patient care and rationales?? Health Science Science Nursing RNSG 1161 Share QuestionEmailCopy link Comments (0)
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