Refer to “Sallie Mae Fisher’s Health History and Discharge Orders” for specifics related to the case study used to inform the assignment.
Using “Home Visit With Sallie Mae Fisher findings” and “Sallie Mae Fisher’s Health History and Discharge Orders,” complete the following components of this assignment:
After viewing the home visit findings, write an essay of 500-750-words in which you do the following:
Identify, prioritize, and describe at least four problems.
Provide substantiating evidence (assessment data) for each problem identified.
Identify and describe at least four medical and/or nursing interventions.
Discuss your rationale for the interventions identified.
Prepare this step of the assignment according to the APA guidelines.
Sallie Mae Fisher’s Health History and Discharge Orders
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:
Digoxin 0.25 mg once a day
Lasix 80 mg twice a day
Calan 240 mg once a day
Order written to continue other home meds.
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
home visit findings
area rug on the floor- fall hazard
Door unlocked, she doesn’t answer it, just tells person to “come in” without looking to see who is there- safety hazard
Dehydrated- tenting present, dry mucous membranes, BP 90/56
No appetite- eating canned soup- lost 14 pounds in 1 week
Not using prescribed O2- resp rate 24,
No BM for 3 days, likely due to dehydration
Lonely, widowed and her daughter is “busy
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