Question

Write a Care Plan for: 84 yr old female with past medical history of vascular dementia HTN, aortic stenosis, CAD s/p AVR and CABG (3/11/16) with recent admission (8/28/2020) and (09/02/2020) for agitation presenting to ED for agitation. Patient states that she is confused as to why she is in a the ED because she doesn't feel sick, but according to the EMS report, her daughter called the EMS as she was concerned about aggressive behavior toward her father. Patient is frustrated that she is back in the ED against her will and states that her daughter is "not with me" and denies daughter's claims. Per last admission the patient was deemed to have full capacity and discharged home on new seroquel rx per psych. She went home with an HHA that she states "stole her pills "and she does not get along with the HHA, although she is able to preform from ADLs and take her medications without assistance from HHA. Here as a social admit, pending dispo.

Medications

aspirin, 81mg, oral, daily.

atorvastatin, 40mg, oral, nightly.

enoxaparin, 40mg, subcutaneous, daily

furosemide, 40,g,oral, daily.

metoprolol succinate er, 25mg, oral, daily.

quetiapine, 100mg ,oral, nightly.

sertaline, 150mg, oral, daily

Answer 1

Care plan

Diagnosis: 84 year old lady with psychiatric illness and past history of coronary artery disease and aortic stenosis, vascular dementia, hypertension has underwent AVR and CABG on (3/11/16)

Lab investigation : daily serum electrolytes monitoring

On examination : agitated and confused

PR : 88/min

BP : 120/80mm of hg

Medicine:

1. Inj Enoxaprin 400mg OD Subcutaneous

2.Tab Aspirin 81mg OD

3.Tab. Atorvastatin 40mg HS

4.Tab Furosemide 40mg OF

5. Tab Metoprolol succinate 25;mg OD

6.Tab Quetiapine 100mg HS

7. Tab Sertaline 150mg OD