SOLVED299

Upon admission at 1220 to the cardiac step down unit your assessment of C.A. includes: VS: T 37.4° C (99.3° F), BP 136/88, P 88 and regular, R 24 and slightly labored. O2 saturation 96% on 2 L 02 via nasal cannula. States that her leg still tingles a bit where the catheter was inserted, but she does not really have pain. States that she “doesn’t feel that great.” A&Ox4, but sleepy. PERRLA. Lungs clear. Apical pulse is 88 and regular. Abdomen is soft, round, and nontender. BS present in all four quadrants. Skin warm and dry. Small scab with a 10cm ecchymotic area in right femoral area, no active bleeding. Pedal pulses 2+ bilaterally. 22-gauge saline lock in left hand. No redness or swelling at site. C.A.’s husband and adult daughter are in the room with her. They are conversing quietly. C.A. has advance directives on file and is a full code. Current orders: Vital signs a 2 hr, up with assistance, SCDs while in bed, 24-hour telemetry monitoring, saline lock, flush with 10 mL NS q 8 hr. PT/INR in the morning. Medications: enoxaparin 120 mg subcut daily; warfarin 2 mg at 1600, call with INR for tomorrow’s dosage; lisinopril 20 mg PO daily; atorvastatin 20 mg PO daily; morphine 2 mg IV push q 3 hr PRN for moderate to severe pain (4-10/10); acetaminophen 500 mg tablets, two tablets PO PRN for mild pain (1-3/10). 5. What is the rationale of administering enoxaparin and warfarin to C.A.?
SCIENCE
HEALTH SCIENCE
NURSING

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