Sallie Mae Fisher Health History:
Ms. Fisher is an 82-year-old female with a history of chronic congestive heart failure (CHF), atrial fibrillation, and hypertension. During the last 6 months, she has been hospitalized four times for exacerbation of her CHF. She was discharged home last Saturday from the hospital after a 3-day stay to treat increased dyspnea, an 8-pound weight gain, and chest pain.
Ms. Fisher is recently widowed and lives alone. She has a daughter, Thelma Jean, who lives in town, but works full time and has family issues of her own. Therefore, family support is limited.
Hospital Discharge Instructions
• Mountain Top Home Health to evaluate cardio-pulmonary status, medication management, and home safety.
• Medical Equipment Company to deliver oxygen concentrator and instruct patient in use. O2 at 2 liters per nasal prongs PRN.
• Prescriptions given at discharge:
o Digoxin 0.25 mg once a day
o Lasix 80 mg twice a day
o Calan 240 mg once a day
• Order written to continue other home meds.
Sallie Mae's Home Medication List
• Zocar 50 mg once a day
• Minipres 1 mg once a day
• Vasotec 10 mg twice a day
• Prilosec 20 mg once a day
• Furosemide 40 mg once a day
• Effexor 37.5 mg at bedtime
• Lanoxin 0.125 mg every other day
• Multivitamin once a day
• Potassium 40 mEq once a day
• Ibuprofen 400 mg q 4 hours as needed for pain
• Darvocet N 100 mg q 4 hours as needed for pain
• Nitroglycerin ointment, apply 1 inch every day
After viewing the home visit, describe the problem (knowledge deficit/disturbed thought process), provide assessment data for the problem, identify and describe the medical/or nursing interventions, describe rationale for the interventions identified. Discussion of rationale includes support from outside resources (current evidence-based literature).© BrainMass Inc. brainmass.com October 25, 2018, 8:59 am ad1c9bdddf
The most striking knowledge deficit in this case is the redundancy of certain medications and the huge number she is taking. The first intervention is to review her medications, get rid of duplicates, eliminate those with bad side-effects and interactions, and possibly prescribe one medication that will do the job of two or even three. While doing this, keep two top priorities in mind: maintain her airway and decrease her depression. Unfortunately, the suicide rate amongst the ill elderly is very high and with the recent passing of her husband, is at even higher risk than the rest of the population.
She is on a whopping dose of furosemide (Lasix). If it doesn't compromise her breathing and edema, I would get rid of the 40 mg dose. Dosing of Lasix should be early, say 8 am and noon or no later than 4 pm so that she isn't up all night going to the ...
The expert analyzes health history and discharge orders. Cardio-pulmonary status, medication management and home safety are discussed.
Develop a Medical Records Policy
I need help in developing a medical record policy. How do you go about gathering the following information?
- The contents of a medical record (example, what information goes in a record)
- Guidelines for properly making an entry in a medical record (example, how to do so, how to make a correction, etc.)