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Julia Monroe, 74-year-old, widowed, female arrived to floor alone last night. She was admitted from

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Asked by ashmc1996

Julia Monroe, 74-year-old, widowed, female arrived to floor alone last night. She was

admitted from the ER complaining of swelling in her legs as well as having gained 5 lbs

over the past two days. Chest x-ray and EKG were unremarkable. She stated that her

legs were hurting most of the night. She has a medical history of hypertension and

hypothyroidism. She was admitted to Dr. Gray for full diagnostic work up to determine

the cause of her symptoms.

 

Patient is scheduled for an Echocardiogram and MRI this AM. You are entering the

room for the first time.

 

The diagnostic tests were completed, and Dr. Gray has informed the patient of the

diagnosis of Heart failure and will be treated with digoxin. Upon entering the room, the

patient is crying and asks when will the medication fix her heart.

 

A few days later, you are assigned to the same patient. She receives her morning

medications including levothyroxine, diltiazem, and digoxin. After your morning

assessment, the patient’s call light goes on and she is complaining of nausea,

abdominal pain, and seeing “yellow circles”. Upon entering the room, the patient is

standing by the bed.

 

The labs return with digoxin level of 10.5 ng/mL. Potassium 5.3 mEq/L. Other labs were

within normal levels The healthcare provider orders digoxin immune fab to be given.

 

Four hours later, the telemetry tech calls and states the patient is sinus tachycardiac

102 with occasional multi-focal PVC’s, patient is now complaining of cramping in her legs. Her last potassium level was 3.2 mEq/mL. She appears short of breath when talking.

 

Provide an SBAR for this patient. 

SCIENCE
HEALTH SCIENCE
NURSING
BSN 246

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