NUR 3805 Electronic Health Record Case Study B: Jones Mr. Johnny Jones, an eighty-five-year-old male presented to the emergency department (ED) with…
Question NUR 3805 Electronic Health RecordCase Study B: Mr. JonesMr. Johnny Jones, an eighty-five-year-old male presented to the emergency department (ED) with a closed-head injury from a fall. He was transferred via ambulance from an assisted living facility. He has one daughter that lives out of state. Mr. Jones was alert and oriented to person, place, and time but still a poor historian. His family was not available during the intake process. However, he did disclose to the nurse he takes medicine for blood pressure and maybe something else. Mr. Jones communicated to the ED nurse his primary care doctor told him to cut back on salty foods. He also told the ED nurse he is not able to get around like he used to, so that is why he lives in an assisted living facility. Mr. Jones was headed to the dining room for lunch when his right knee “gave away” which led to his fall. When the ED nurse asked Mr. Jones for his daughter’s contact information, he was not able to recall his daughter’s number. The nurse proceeded to reconcile his medications. Mr. Jones stated he takes two blood pressure pills, a baby aspirin, and a new medicine that the doctor gave him two months ago. He described the new medicine as a “tiny white pill.” After becoming frustrated, Mr. Jones told the nurse, “I was just here a few months ago when I had my heart attack, you should have my records.” He also inquired, “Aren’t my records in the clouds”?Based on the Mr. Jones’s interview, the health team concluded he had a medical history of hypertension, past myocardial infarction, and arthritis. A medication list based on Mr. Jones’s past ED visit:· HCTZ 25 mg by mouth twice daily· Atenolol 50 mg by mouth daily· ASA 81 mg by mouth daily· Aleve as needed for pain· Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times During Mr. Jones’s interview, he mentioned his previous ED visit after having a heart attack. After reviewing his discharge medications from the prior ED visit, it was determined he was given a new prescription for digoxin 0.5 mg and Coumadin 3 mg by mouth daily for treatment of atrial fibrillation. After a review of his demographical information from his last ED visit, a power of attorney (POA) for healthcare document was located. The healthcare document included the POA’s contact information, Mr. Jones’s daughter. The ED nurse spoke with Mr. Jones’s daughter and was able to reconcile his medication list. She obtained the list from her father’s local pharmacy.The ED uses an electronic health record program, Mediscript, which verifies and compiles patients’ medications from outpatient/community pharmacies. After the list was compiled for Mr. Jones, here were the final results: · HCTZ 25 mg by mouth twice daily· Atenolol 50 mg by mouth daily· ASA 81 mg by mouth daily· Aleve as needed for pain· Nitro SL 0.4 mg as needed for chest pain/ 1 tablet every 5 minutes as needed up to 3 times · Digoxin 0.5 mg by mouth daily· Coumadin 3 m by mouth dailyBased on the health assessments and interviews, the health team concluded the Mr. Jones had a medical history of hypertension, past myocardial infarction, arthritis, and atrial fib. The ED physician ordered an EKG, CBC, BMP, dig level, PT/INR, and CT scan of the head without contrast. These diagnostics were ordered based on Mr. Jones’s chief complaint, history and the review of the electronic health record. The diagnostics revealed Mr. Jones has a subdural hematoma, his INR is 8.0, and his dig level was toxic. He was admitted and transferred to the Neurological ICU for observation and care. Questions for Discussion:1) What is believed to be the cause(s) of the Mr. Jones’s successful diagnoses and plan of care? 2.) Summarize the case study above 3) provide a conclusion of Mr. jones case Health Science Science Nursing NUR 3805 Share QuestionEmailCopy link Comments (0)
