Gerontological Nursing Case Study: Medication Use and the Frail Elderly

This case study was inspired by a late-night encounter in the ER. Unfortunately, medication mismanagement scenarios such as these are all too common in the hospital environment and represent a significant threat to the health and well being of the frail elderly population.

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Gerontological Nursing Case Study: Medication Use and the Frail Elderly

Presentation

Isabella Hill*, an 89-year-old African American female, is brought into the emergency department late one evening by her worried middle-aged daughter.

Present History

The daughter is very concerned about her mother's increasing generalized weakness, vague complaints of aches and pains, intermittent shortness of breath, and poor appetite. The daughter claims that the client has vomited "once or twice" during the past 24 hours with "occasional" complaints of nausea, but has displayed her usual pattern of voiding and bowel elimination. The client denies any abdominal pain.

The daughter laments, "She won't eat a thing! She has lost 20 pounds during the past three weeks!"

Mrs. Hill is a widow who lives alone.

She was just released from the hospital two weeks prior with a medical diagnosis of heart failure exacerbation.

The Registered Nurse (RN) performs an assessment.

Assessment Data

  • weak, elderly female who has difficulty standing or walking unassisted
  • alert and oriented to person, place, time, and situation
  • able to talk in complete coherent phrases
  • able to move all extremities equally
  • respirations even, shallow, and unlabored with lung fields clear to auscultation but diminished at bases throughout
  • irregular heart rhythm with grade 3/6 systolic murmur noted in the aortic and pulmonic regions
  • abdomen soft, nondistended, and nontender with bowel sounds present in all four quadrants
  • skin is intact, warm centrally with cool extremities, and dry with loose turgor
  • pulses are palpable +2 upper extremities and +1 lower extremities
  • capillary refill is instant
  • no edema or jugular vein distention present
  • Weight registers 98 pounds on the stretcher scales; her last recorded weight in the hospital was 112 pounds

Vital Signs

  • 99.6 F oral
  • 39 heart rate
  • 22 respiratory rate
  • 139/46 blood pressure
  • SaO2 92% on room air

Intervention

She is placed on oxygen at 2 liters per nasal cannula and her oxygen saturation increases to 99%.

She currently denies all pain.

Diagnostic Tests

  • Electrocardiogram reveals atrial fibrillation with no acute changes
  • Portable chest and abdominal x-rays are essentially normal for a person her age

Present Medical and Surgical History

  • end-stage congestive heart failure with an ejection fraction of 20-25%
  • essential hypertension
  • atrial-fibrillation
  • aortic stenosis
  • age-related macular degeneration
  • chronic renal insufficiency
  • dysphagia
  • right total hip replacement

Current Medications

  • Cordarone (amiodarone HCl) 200 mg oral daily
  • Coumadin (warfarin sodium) 2.5 mg oral every evening
  • Lanoxin (digoxin) 0.125 mg oral daily
  • Nexium (esomeprazole magnesium) 20 mg oral daily before breakfast
  • Coreg (carvedilol) 3.125 mg oral twice daily
  • Lasix (furosemide) 20 mg oral daily
  • Potassium chloride 20 mEq oral daily

A complete "rainbow" of blood work is drawn, plus a urinalysis.

Laboratory Results

  • Prothrombin 35 seconds
  • INR 6.5
  • K+ 5.2 mEq/L
  • Blood urea nitrogen 48 mg/dL
  • Serum creatinine 2.2 mg/dL
  • Digoxin level 2.4 ng/ mL

According to your analysis of the case, what factors are contributing to Mrs. Hill's presenting signs and symptoms?

Should she continue her current medication regimen? Why or why not?

Which medications should be continued and which medications should be eliminated?

What treatments or interventions do you anticipate being ordered for this client?

*patient information changed for privacy concerns

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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VickyRN

About VickyRN, MSN, DNP, RN

VickyRN, PhD, RN, is a certified nurse educator (NLN) and certified gerontology nurse (ANCC).

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Specializes in adult ICU.

This is a nice case study -- would make a good teaching tool. I can spot all the answers you are trying to get at (I think, don't really know for sure as you didn't post them) but I have 10+ years experience in acute care, so I suspect that one would hope that is the case! I love the graphic, as well (who did that? it's really nice.)

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Specializes in Gerontological, cardiac, med-surg, peds.

Thanks for your interest in the case study, grandmawrinkle (love your username!). I am using this case study in my "Health of the Older Adult" class this semester and I'm sure it will generate much discussion and critical thinking. I cannot take credit for the cool graphic. Joe V, our allnurses Systems Administrator furnished it :)

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No spoilers here, but the lab results made me go :eek: !

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(small rant here) I actually encountered a question like this on a compentency test while applying for a job. In addition to the info provided on this question about the patient, there was a set of admitting orders from ER physician to the unit. This was a test for telemetry nurses by the way. I did exactly what I would have done in the clinical situation. I carefully look at the ER orders to make sure dig, lasix and potassium were not ordered. They were not on the orders sheet so I did not say, "hold the dig, lasix and potassium". I got a zero for the question because I did not say "hold the dig, lasix and potassium". My question for the test giver was, "how can I hold something that is not ordered?" The answer was that the action was so central to the patients condition that it needed to be stated in the answer. I was OK with that but I couldn't help thinking that it showed something I knew as a student but had forgotten after many years at bedside. When taking a test like this you have to ask yourself what the tester is getting at and what they want but not what you actually would do at the bedside. By the way, there were many other questions in the compentency that I did well on and my score was acceptable for employment and I got the job.

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I'm very slow in critical analysis that's why I love forum like this for practice.

Here are some points that I noted:

Prothrombin, INR, BUN, Crea and Dig level are high

Weight loss: could it be from diuresis?

Meds: Hold Dig, Coumadin & Amniodarone (having her heart rate of 39)

Hope people would look into this and share some insights.

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Specializes in neuro/ortho med surge 4.

Would you not hold the beta blocker for HR of 39?

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Specializes in Gerontological, cardiac, med-surg, peds.

You're on the right track, tummyhealer and sistasoul :)

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Specializes in Case Management.

Vitamin K and some Kayexelate probably wouldn't hurt!

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What about holding the lasix for dehydration with a high BUN ?

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Would hold B-blocker Coreg b/c low pulse 39.

K+ is slightly elevated. Is KCL necessary?

Bun and Creat are elevated. Could possibly cause K to be retained. She also needs to be hydrated due to the high BUN

Pt has very low ejection fraction probably due to a.fib. Administering digoxin could help with contractility and CO.

PT is a bit low. It's supposed to be 2.5x ctl. for coumadin

Dont give her anything that would cause her to aspirate due to dysphagia

Since she's s/p for hip replacement, we need to keep her legs from adducting

blood test result reveals high dig level

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CXR, could have aspiration pneumonia with low grade temp, low o2 sat, intermitent SOB h/o dysphagia. Dig level high especially for this age group and may be causing her vomiting and anorexia

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