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.
SpecialtiesEducatorsCase Study
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?
