Medical Diagnosis :
Current Labs :
Current Labs normal
Status post-myocardial infarction
History of Present Illness:
Mr. R is an 81-year-old male who experienced a mild posterior myocardial infarction one week ago. Due to his age and his overall physical condition, a conservative approach was taken. He was on telemetry following the infarction and initially experienced some premature ventricular contractions that were successfully treated with intravenous Lidocaine. He has had no dysrhythmias for the past 4 days, and his condition has remained stable. He is being transferred to the Skilled Nursing Unit from the Medical-Surgical Unit for generalized rehabilitation and evaluation for long-term care.
Past Medical History:
Smoker for 45 years. Stopped smoking at age 65. In the past consumed “multiple beers” on weekends but has not had any alcohol intake for the past several years.
Mother died at age 70 from diabetes; father died at age 62 from myocardial infarction. Adult children are all healthy; they have a son with hypertension, another son has type 2 diabetes.
Prior to admission, the patient was on Atorvastatin 20 mg PO daily; Tacrine 30 mg PO 4 times/day; and Furosemide 20 mg PO daily.
Review of Systems:
General health status: Daughter reports overall have been healthy, but health has declined recently as dementia has become more pronounced, and with the recent death of wife.
Integumentary: Daughter reports no skin problems, denies the presence of lesions, rashes, or itching.
Cardiovascular: Daughter states patient had never experienced chest pain until his infarction. Patient gets short of breath with activity. No reports of problems with circulation.
Respiratory: No recent colds, occasional cough, no reports of dyspnea.
Gastrointestinal: Daughter states no problems with digestion or food intolerances other than allergy to nuts, no problems with elimination reported.
Musculoskeletal: No reported problems with muscles or bones. The daughter indicates the patient ambulated independently prior to hospitalization.
Central Nervous System: Daughter reports recent cognitive changes–less oriented, easily confused, and problems with anxiety.
Elderly adult Hispanic male in no physical distress, confused to time and place
O2 sat 95% on room air
Normocephalic, eyes clear, PERLA, mouth without lesions, teeth in good condition; neck supple, thyroid within normal limits
Lungs clear to auscultation bilaterally. Respirations are even and unlabored.
S1 and S2 within normal limits; no murmurs. No lifts, heaves, thrills noted.
Abdomen soft, non-tender; bowel sounds in all quadrants. No masses are palpable.
Moves all extremities; pulses 2+; no edema
Skin is clean, dry, intact; no lesions present
Within normal limits
Within normal limits
Mental status: Alert to person, not alert to time or place. Patient anxious during the examination.
One-week status post-myocardial infarction; has dementia and anxiety disorder.
1. Admit to Skilled Nursing Unit for general rehabilitation.
2. Discuss with family long-term placement options.
3. Consult with psychiatry for the treatment of anxiety disorder.
Day/Time Orders Signature
Wed 0730 Order Type: G M.D.
1. Discontinue Oxazepam per family request until Psychiatric consult completed and new orders written. (telephone order)
Day/Time Orders Signature
Tue 1400 Order Type: G, M.D.
1. Lorazepam 0.5 mg PO every 12 hours PRN for anxiety.
2. Psychiatric consult for anxiety disorder.
Day/Time Orders Signature
Mon 1500 Order Type: Gerald Moher,
1. Transfer to the Skilled Nursing Unit.
2. Vital signs every 8 hours.
3. Intake and Output every 8 hours.
4. Diet: 2000 Kcal, low fat, low salt.
5. Activity: Unrestricted.
6. Timolol maleate 15 mg PO twice a day.
7. Lisinopril 10 mg PO once a day.
8. Tacrine 30 mg four times a day.
9. Oxazepam 15 mg PO three times a day.
10. Triazolam 0.125 mg PO at bedtime.
11. Dipyridamole 50 mg PO four times a day.
12. Aspirin 325 mg PO once a day.
13. Atorvastatin calcium 20 mg PO once a day.
14. Physical therapy consult/treatment plan.
Friends do not visit him. The patient is confused; he does not often recall when family members come by. Social History: Smoker for 45years.Stopped smoking at age 65. In the past consumed “multiple beers “on weekends But Has not had any Alcohol intake for the past several years. Medications: Prior to admission the patient was on Atorvastatin 20mg PO daily; Tacrine 30mg PO 4 times/day; and Furosemide 20mg PO daily.
Timolol maleate 15mg PO twice a day. Lisinopril 10mg PO once a day. Tacrine 30mg four times a day. 9.Oxazepam 15mg PO three times a day. 10.Triazolam 0.125mg PO at bedtime.11. Dipyridamole 50mg PO four times a day. 12.Aspirin 325mg PO once a day. 13.Atorvastatin calcium 20mg PO once a day
14.Physical the rap consult/treatment plan. Atorvastatin calcium 20mg PO daily. Tacrine 30mg PO 4 times/day, Furosemide 20mg PO daily, has age neural anxiety disorder that has been worse since wife died. She also has dementia.
No use of alcohol for several years. Has never used drugs. Tobacco used for approximately 40 years, quit at age 65. Drinks coffee in the morning.
The daughter states that he has had dementia that has affected his ability to care for himself. After wife died, he had problems with anxiety. The heart attack has just made him weaker.
Daughter wants to know if he will be able to return home with her. She and her brothers are afraid to place him in a nursing home, yet the daughter indicates she is unsure she can take care of him anymore. a. Integrity: Skin intact, warm, and dry b. Turgor: Within normal limits
1.Orientation: Daughter states confusion comes and goes. He is always oriented to person but often is confused about time and place—particularly in the hospital. Family processes: Sees sons and daughter regularly. Lives with daughter and daughter has full care of him since death of mother. Daughter states it is increasingly difficult to care for her father. 3. Care-giving role: Completely depends on daughter
Tue 1100 Fluctuating level of consciousness; behavior erratic. I will order a psychiatric consult for anxiety disorder.
Mon 1500 Admit to the Skilled Nursing Unit for general rehabilitation status post myocardial infraction one week ago. Because of dementia and anxiety disorder, he needs an evaluation for long-term placement as opposed to sending a patient home in the care of the daughter. Discharge coordinator to see family about long-term placement. PSYCHIATRIC CONSULT Date: Wednesday Time: 1400 Reason for consultation: This 81-year-old Hispanic widowed male is one-week post-M And was transferred to the Skilled Nursing Unit for rehab prior to returning home. Evaluation of psychiatric conditions and treatments with possible follow-up was requested, which is a quest for family assessment related to the appropriateness of disposition back to the home of his daughter or to a nursing home. Additionally, he is combative with staff at times and has difficulty communicating his needs. Staff and family education, discussion of community resources for dementia, and evaluation for elder abuse potential were requested as well.
Wed 0645 Shift summary: Patients left only part of the night; Lorazepam effective in calming patient; slept well after 0400—remains asleep. Ms. A, RN Nurse’s Notes Day /Time Notes Signature Wed 0300 Patient awake and very anxious, agitated, and combative. Unable to calm patient. Lorazepam administered. Ms. A, RN Nurse’s Notes Day/Time Notes Signature Tue 2030 Assessment complete and documented on the EPR. Patient very sleepy this evening. Patient’s sons and daughter with patient in lobby area. RN Day/Time Notes Signature Tue 1830 Shift summary: Patient agitation decreased after Lorazepam administered. The patient slept the latter part of afternoon. Sons were in this afternoon and requested to take father home; do not agree with need for long-term placement. Daughter questions why he has been sleepy this afternoon. Nursing aide indicates little dinner was eaten. Susan Hunter, RN Nurse’s Notes Day/Time Notes Signature Tue 1500 Patient slept soundly a good part of the morning. I was unable to participate in physical therapy due to drowsiness. When awake, the patient anxious, and confused. The physician called to obtain an order for Lorazepam, administered as ordered to help reduce anxiety. RN Nurse’s Notes Day/Time Notes Signature Tue 0730 Shift assessment complete. No changes from baseline—patient remains anxious. Unwilling to go to dining hall for breakfast. RN Nurse’s Notes Day/Time Notes Signature Tue 0600 Shift summary: Patient had restless night—up several times wandering the halls, looking for his daughter. Became angry when assisted back to his room and into bed. Anxious and agitated behavior noted. RN Nurse’s Notes Day/Time Notes Signature Mon 2000 Shift assessment complete—no changes from the baseline assessment. Patient continues to be confused and agitated. The daughter has left for the evening. RN Nurse’s Notes Day/Time Notes Signature Mon 1850 Shift summary: Patient admitted this afternoon; patient and daughter oriented to the unit, routines, and expectations. Patient very anxious and agitated and confused this afternoon. Daughter indicate she is more confused than he typically is at home. She suspects the change in environment is partly to blame. RN Nurse’s Notes Day/Time Notes Signature Mon 1500 Patient admitted to the Skilled Nursing Unit with daughter present. The patient had been cent myocardial infarction and has an anxiety disorder, dementia, hypertension, and hyperlipidemia. Admission assessment complete. The client is very anxious about the change in the environment. Minimum Data Set (MDS) form initiated. MDS coordinator notified. S.RN.
Please need SBAR for MR. R
Nursing Concerns/Interventions :
Current medications & uses:.Get Nursing Assignments Help Today
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