Name: George Davis; Gender: Male; Age: 65; Marital Status: Married Weight: 271 lbs (122.93 kg); Height: 70 inches; Race: Caucasian; Religion: : Agnostic Allergies: None known; Immunizations Up to date Occupation: Retired; Address: New York, USA Provider: Dr. Potter, MD, and RN and Nursing Assistant Major Support: Delilah Davis, Wife. Phone number: 605-475-6961 History George presents to the ER with recurrent headaches, fatigue, and a blood pressure of 185/102. The patient is a long-time smoker, leads a relatively sedentary lifestyle, and has a BMI of 39. He has a history of acid reflux. The plan is to keep George overnight for observation and to administer medications to help control his blood pressure. Medications *Hydrochlorothiazide 25 mg oral Daily 0900 5 mg oral Daily 2000 Dosage Route Frequency Hours/Date of Administration Pantoprazole 20 mg oral Daily 0900 *Simvastatin 40 mg oral Daily 0900 Notes: Patient’s blood pressure taken just before transferring to the Med/Surg floor: 156/87. On admission to the Med/Surg floor, Vital signs taken by the Nursing Assistant were reported to the RN. Temp. 98.8 F, Pulse 101, B/P 178/98. The Nursing Assistant reported to the RN that the patient is complaining of pain in his chest. Orders:• Obtain vital signs every 4 hours. Call physician if B/P is greater than 165/90. • Obtain a STAT ECG for chest pain • Pantoprazole 20mg oral daily • Simvastatin 40mg oral daily • Lisinopril 30mg oral daily • Hydrochlorothiazide 25mg oral daily What would be the priority nursing intervention for Mr. Davis based on the Electronic Health Record information?
Name: George Davis; Gender: Male; Age: 65; Marital Status: Married
Weight: 271 lbs (122.93 kg); Height: 70 inches; Race: Caucasian; Religion: : Agnostic
Allergies: None known; Immunizations Up to date
Occupation: Retired; Address: New York, USA
Provider: Dr. Potter, MD, and RN and Nursing Assistant
Major Support: Delilah Davis, Wife. Phone number: 605-475-6961
History George presents to the ER with recurrent headaches, fatigue, and a blood pressure of 185/102. The patient is a long-time smoker, leads a relatively sedentary lifestyle, and has a BMI of 39. He has a history of acid reflux. The plan is to keep George overnight for observation and to administer medications to help control his blood pressure.
Medications *Hydrochlorothiazide 25 mg oral Daily 0900 5 mg oral Daily 2000 Dosage Route Frequency Hours/Date of Administration Pantoprazole 20 mg oral Daily 0900 *Simvastatin 40 mg oral Daily 0900
Notes: Patient’s blood pressure taken just before transferring to the Med/Surg floor: 156/87. On admission to the Med/Surg floor, Vital signs taken by the Nursing Assistant were reported to the RN. Temp. 98.8 F, Pulse 101, B/P 178/98. The Nursing Assistant reported to the RN that the patient is complaining of pain in his chest.
Orders:• Obtain vital signs every 4 hours. Call physician if B/P is greater than 165/90. • Obtain a STAT ECG for chest pain • Pantoprazole 20mg oral daily • Simvastatin 40mg oral daily • Lisinopril 30mg oral daily • Hydrochlorothiazide 25mg oral daily
What would be the priority nursing intervention for Mr. Davis based on the Electronic Health Record information?
Step by step
Solved in 3 steps
