Question

The home health nurse visits a 76-year-old woman, M. J., who lives on the side of a very steep mountain, once a week for the last year. M. J. has diabetes mellitus, hypertension and hyperthyroidism and is in atrial fibrillation. She stopped smoking 5 years ago but before that she smoked one-half pack a day. Her last week laboratory test results include internal normalized ration (INR) 1.7, sodium 129, potassium 5.8, chloride 102, carbon dioxide 20, haemoglobin A1C (HgbA1C) 8.3, blood urea nitrogen (BUN) 45, creatinine 1.5, Hgb 10.1, platelets 215,000, leucocyte count 6.8 and glucose 289.

It is noted by the home health nurse that M. J. had a 5-min spell of visual loss in her right eye which has not recurred; however, during this period, the patient felt her left leg and left hand “funny,” and her left leg and foot got so weak that she was unable to walk. She has a heart murmur which is loudest over the right sternal border and more prominent during the systolic phase. M.J. also hears bruits on both sides of her neck with the right side being louder than the left. Her vital signs include blood pressure (BP) 135/72 (in right arm) and 110/66 (in left arm), irregular heart rate, i.e. 75 to 90 beats per minute and 90% to 92% oxygen saturation at room temperature.

Q1 what is the main concerns regarding MJ as a provider?

Q2 based on the lab results given what changes would you make in her medication profile?

Answer 1

1.The main concern for the provider in this case are

• Elevated blood sugar level, decreased carbindioxide level ,elevated HbA1C,associated with diabetic ketoacidosis.
• A decrease level of sodium along with decreased carbindioxide level has to be corrected or else will lead patient to confusion by electrolyte imbalance and saturation alterations
• The elevated BUN and creatinine level is an indicator of kidney insult due to the condition
• Hypotension and Hypoxia are the priority concern for a provider to treat and support the patient.

2.In view to the lab values the following changes are necessary

• A beta blocker or an calcium channel blocker to treat arrythmia
• IV fluid (NaCl) to correct hyponatremia,hypotension
• Electrolyte to balance the acid base balance and helpful in correction of blood gas values
• She has to be assessed for any abnormalities in the central nervous system as patient is experiencing weakness in one side,inability to walk
• Blood thinners to relieve any blocks or any abnormalities in the artery causing  the bruits which is a risk factor of coronary artery disease