Identify, prioritize, and describe one problem.

Provide substantiating evidence for the identified problem.

Identify and describe medical and / or nursing interventions.

Discuss your rationale for the interventions identified.

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:

o Digoxin 0.25 mg once a day

o Lasix 80 mg twice a day

o Calan 240 mg once a day

• Order written to continue other home meds.

Sallie Mae's Home Medication List

• 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

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