I. Initial Presentation:
Marilyn Fitch is a 78-year-old Caucasian woman with a history of hypercholesteremia, hypertension, and heart
failure and has
... [Show More] NKDA. She was brought in by her daughter after Marilyn complained of feeling dizzy several
times this morning and then almost passed out at home. Marilyn has a six-month history of paroxysmal atrial
fibrillation. Her heart rate has been regular and she has had no episodic dizziness since she had a synchronized
cardioversion one week prior to this visit. Her initial VS in triage were: T: 98.9 F/37.2 C (oral) P: 52 R: 16 BP:
94/52 and O2 sat: 98% room air.
Personal/Social History:
Marilyn is a widow and lives alone in her own home. She denies smoking and admits to drinking one glass of
wine with her dinner.
1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by
the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present
Problem:
Clinical Significance:
Hypercholesterolemia
Hypertension
Heart failure
Dizziness/ almost passing out
6-month paroxysmal A fib
Synchronized cardioversion
Pulse of 52, BP 94/52
All of these are risk factors (especially when
combined) for heart attack and stroke
Concerning signs of heart rhythm changes
Vitals of low HR and Low BP, usually if one of these
two vitals changes, the other will increase to
compensate.
RELEVANT Data from Social History: Clinical Significance:
Widow and lives alone
Drinking wine with dinner
Shows the pt doesn’t have much of a support system,
and there could be psychosocial aspects to include in
her care
Drinking 1 glass of wine with dinner is usually ok, in a
healthy individual. Since she has heart problems,
cholesterol issues and hypertension, she should restrict
alcohol use.
2. What is the RELATIONSHIP of the past medical history and current medications? Why is your patient
receiving these medications? (Which medication treats which condition? Draw lines to connect)
Medical History (PMH): Home Medications:
Hypercholesteremia
Hypertension
Heart failure
Atrial fibrillation
Apixaban 2.5 mg po bid
Captopril 100 mg po BID daily
Amiodarone 100 mg po bid
Hydrochlorothiazide 50 mg po daily
Atorvastatin 10 mg po daily
Carvedilol 6.25 mg po bid
As the nurse responsible for this patient, you promptly review the medical
history and current home medications in the medical record: [Show Less]