Naomi Bell, age 90, was admitted to the hospital yesterday after experiencing chest pain. She wears a hearing aid in her left ear. In the report you were told that she is “confused” and “doesn't answer questions appropriately.” Her vital signs overnight were as follows: temperature, 98.0°F; pulse, 62 beats/min; respirations, 18 breaths/min; blood pressure, 132/86 mm Hg. She is due for her morning medications. As you give Mrs. Bell her medications and state their purpose, she points to the digoxin and says, “Honey, I don't take that pill.”
Prescribed Interventions
- Digoxin 0.125 mg PO every morning
- Enteric-coated aspirin 81 mg PO every day
- Furosemide 20 mg PO every morning
- Famotidine 20 mg PO BID
- Potassium chloride 10 mEq PO every morning
- Captopril 50 mg PO TID
Developing Clinical Reasoning and Clinical Judgment
- How would you respond to Mrs. Bell's statement, “Honey, I don't take that pill”?
- Suggest ways in which you can confirm that you are giving Mrs. Bell the correct medications.
- Identify the medications that require assessment before administration.
- Describe factors that can contribute to inappropriate answers, and identify nursing actions to diminish these factors.
- How would you determine Mrs. Bell's level of confusion, if any?
Suggested Responses for Integrated Nursing Care
- When patients question you regarding their medications, listen to them. Questions like this should send a “red flag” to the nurse. Often, patients are familiar with what they normally take and can alert you that this may not be the right medication. Do not insist that Mrs. Bell take the digoxin until you confirm the accuracy of the prescribed intervention. In this case, it could be that Mrs. Bell just did not hear what you said. Always confirm what patients say to you by restating it back to them. It could also be that she is more familiar with the trade name for this drug or the medication may look different from the medication she uses at home.
- You should use multiple safety checks to give medications safely (refer to Chapter 5). Some measures include researching the drug before administration and double-checking all of the “rights.” Compare the electronic medication administration record with the original prescribed intervention in the health record. If the prescribed intervention still remains unclear to you, call the prescriber to clarify it (refer to Chapter 5).
- Some medications require assessment before you administer them to the patient. In this case, Mrs. Bell takes four medications that will require assessment before administration. Digoxin, furosemide, and captopril will affect pulse and blood pressure and these vital signs should be assessed prior to administration (refer to Chapter 2). In addition, laboratory test results should be available on potassium and digoxin levels. If Mrs. Bell has a low pulse rate, low blood pressure, or a toxic laboratory value, you will not administer these medications and will notify the health care provider (refer to Chapter 5).
- Sometimes, older patients become confused in unfamiliar settings—in this case—the hospital. However, do not assume this is always the case. The nurse who gave you the report may have assumed that Mrs. Bell's inappropriate answers were due to confusion, when in fact they may be related to Mrs. Bell's hearing problem. When patients with a hearing impairment are in an unfamiliar setting, such as a hospital admission, encourage them to wear their hearing aids and help them check their batteries to ensure they are working. If you are still unclear whether Mrs. Bell is confused, perform a standard mental status examination used by your institution (refer to Chapter 3). This will establish a baseline assessment of her mental status that you can use to individualize her nursing care plan.
- If you determine Mrs. Bell is confused, assess the source of confusion. Given Mrs. Bell's cardiac condition, assess her respiratory status and oxygen saturation level via pulse oximetry to determine whether she is experiencing hypoxia or ischemia (refer to Chapters 2, 3, and 14). If the cause is physiologic, notify the health care team immediately. Another source contributing to confusion could be isolation caused by hearing loss. One way to reduce possible confusion for Mrs. Bell is to improve communication. Ensure that her hearing aid battery is operating and that the unit is placed correctly. Other ways to improve communication include talking to her at eye level, facing her directly when speaking, or even speaking into her unaffected ear. If Mrs. Bell's vision is better than her hearing, you can also give her pertinent information in writing.