Medication Case Study As you examine your patient’s chart, please address each o

Medication Case Study
As you examine your patient’s chart, please address each of the following questions:
1. What findings in the patient’s chart are most valuable to you based upon the medications the patient is taking? Why?
2. What additional information (physical assessment data, history, etc.) would you like to know about this patient that is not provided? Why?
3. What laboratory studies would you expect to be done for this patient in relation to his medication record? Why?
4. Identify three priority drug interactions among these drugs and what nursing actions are appropriate to implement because of them.
5. Identify three teaching points related to the medication record that you would prioritize for this patient.
Patients Charts:
Medication list: acetaminophen, acetaminophen; hydrocodone, alprazolam, hydrochlorothiazide, lisinopril, vancomycin in 0.9% NACL, rosuvastatin calcium, nicotine patch, metformin hydrochloride, melatonin
Vital Signs:
Temperature 98 °F
Temperature Source Oral
Pulse 88 bpm
Pulse Source Apical
Blood Pressure 152/97
Position Sitting
MAP (Mean Arterial Pressure)
Respirations 18 bpm
SpO2 (%) 96 %
Oxygen Source Room Air
Oxygen Flow Rate
Faces Pain Rating
Numeric Pain Rating 6
Glucose Monitoring Results 177 mg/dL
Body Mass Index 25.8
Substance use:
Tobacco- Smoking: started 20 years. Amount: 1PPD. Would like to quit?: Cessation program offered?:
Location (Where are the symptoms located? Are they local or do they radiate?)
Loss of sensation, non healing wound with purulent drainage and foul odor for one week PTA. No fever, nontoxic appearing.
Assessment
08/30/2023 0820
Head, Face, Anterior Fontanel, Neck
Head, Face Head round and symmetrical, Normocephalic
Anterior Fontanel
Neck Full range of motion
Comment
Eyes, Ears, Nose, Throat
Eyes Symmetrical, No drainage, Denies pain
Eyes Comments
Ears Symmetrical placement, No drainage, No pain
Ears Comments
Nose, Throat
Nose, Throat Comments
Neurological group
Level of Consciousness
Orientation Oriented X4
Cognitive
Speech WDL
Pupil Response Bilateral pupils reactive
Pupil size (mm) left: 3
right: 3
Deep Tendon Reflexes
Neurological Comments Drowsy; arouses to verbal stimuli and is appropriate.
Glasgow Coma Scale
Best Eye Response 3=Eyes open to verbal command
Best Verbal Response 5=Oriented
Best Motor Response 6=Obeys commands for movement
Glasgow Total 15
Respiratory
Resp. Effort/Pattern Regular rhythm, Bilaterally even and unlabored
Breath Sound, Comments Clear bilaterally
Cough None
Sputum
Resp. Interventions
Intervention, Comments
Respiratory Airways/Drains
Airway/Drain, Comments
Oxygen Source Room Air
Oxygen rate and comments
Cardiac
Cardiac Rhythm/Sounds Regular rhythm , Normal Rate, S1 and S2 present
Cardiac Symptoms
Monitors/Telemetry? No
Cardiac Comments
Peripheral Vascular
RUE +2-moderate pulse
LUE +2-moderate pulse
RLE Capillary refill greater than 3 secs, +2-moderate pulse
LLE Capillary refill greater than 3 secs, +2-moderate pulse
Periph. Vasc. Comments
Integumentary
Skin Color
Skin Temperature/Condition Warm, Dry
Skin Turgor
Skin Comments Dressing to right foot
Braden Scale
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
Total score
Risk level
Braden Scale Comments
Musculoskeletal
RUE Full range of mobility
LUE Full range of mobility
RLE Full range of mobility, Weakness
LLE Limited range of mobility, Weakness
Musculoskeletal Comments 1-person assist with walker
Morse Fall Scale
Morse, J.M., “Preventing Patient Falls” 2nd ed (Springer Pub, Fall 2008), Instructions for the use of the scale are in this book.
History of falling 0=No
Secondary diagnosis 15=Yes
Ambulatory aid 0=Bedrest/nurse assist
IV/Saline Lock 20=Yes
Gait/Transferring 10=Weak
Mental Status 0=Oriented to own ability
Total 45
Select Risk level based on total score Low Risk:25-49
Gastrointestinal
Abdomen Soft, Rounded
Bowel Sounds Hypoactive
Passing Flatus Yes
Last Bowel Movement
GI Comment
Genitourinary
Urinary Symptoms
Urine Color
Urine Characteristics
GU Comments
Pain Assessment
Pain Location right foot
Numeric Pain Rating 6
Pain Rating-Faces
Pain Relieved by
Pain Comments
Imaging Results
MRI R Foot
There decreased T1 signal and increased T2 signal due to marrow edema in the right great toe. Loculated area of fluid surrounding second metatarsal – high suspicion for osteomyelitis
Admission Problems
Chief Complaint Right foot wound
Primary Concern – Admission Diagnosis Cellulitis vs. osteomyelitis
Other Problems/Diagnosis NIDDM, HTN, Hyperlipidemia, Tobacco abuse, Anxiety
Note Time Note Type Professional Role Created By
08/29/2023 1020 Daily Note Nurse Practitioner (NP) Megan Lanpher
Primary Diagnosis – POD #0 for right great toe amputation per surgical team. IV Vanc ongoing; blood cultures final sensitivity is pending, hopefully it is MSSA. Will need inpatient vs. home rehab at discharge. Consult case management.
Blood pressure elevated today after surgery; will follow. Sugars are stable. Tolerating nicotine patch.
08/28/2023 1020 Daily Note Nurse Practitioner (NP) Megan Lanpher
Primary diagnosis – MRI R foot ordered; surgery consulted. Continue ABX and wound care.
Secondary diagnoses – Stable.
08/27/2023 1020 Daily Note Nurse Practitioner (NP) Megan Lanpher
Ongoing IV ABX, wound care to R foot. Dressing reveals purulence ongoing, no crepitus. Remaining physical exam is benign. Consider surgical consult if no improvement
DM – marginal blood sugars 160-180 on metformin. BP ok. Started nicotine patch at patient request. Mood stable; he speaks broken English