Discharge Summary Difficulty breathing, hypertension, tachycardia
CHF secondary to mitral valve prolapse
Admitting
Diagnosis:
Final
Diagnosis:
History of
Present
Illness:
Summary
of Hospital
Course:
Patient was brought to the Emergency Room by her family because of difficulty breathing and palpitations
Patient reports that she has experienced these symptoms for the past 6 months, but this episode is more
severe than any previous. Upon admission in the ER, heart rate was 120 beats per minute and blood pressure
was 180/110. The results of an EKG and cardiac enzyme blood tests were normal. She was admitted for a
complete workup for tachycardia and hypertension.
Patient underwent a full battery of diagnostic tests. A prolapsed mitral valve was observed by
echocardiography. A stress test had to be stopped early due to onset of severe difficulty in breathing.
Angiocardiography failed to demonstrate significant CAD. Blood pressure and tachycardia were con-
trolled with medications. At discharge, HR was 88 beats per minute and blood pressure was 165/98.
There was no evidence of a myocardial infarction or significant CAD. Pellent was placed on a low-salt
and low-cholesterol diet. She received instructions on beginning a carefully graded exercise program.
She is to continue her medications. If symptoms are not controlled by these measures, a mitral valve
replacement will be considered.
Discharge
Plans:
Term
Definition

Anurse is teaching a newly licensed nurse about safe medication administration. the nurse should instruct that which of the following actions is included in the 6 rights of medication administration? a. verify dosage calculation with a second nurse. b. obtain a current list of the client’s medications. c. document medication prior to administration. d. compare a new prescription with an old prescription.

Anurse is planning teaching for a client who has asthma about taking montelukast. which of the following should the nurse include about the purpose of this medication? a. relieves acute bronchospasm b. inhibits replication of neutrophils c. controls inflammation in the airways d. activates beta2-receptors in smooth muscle

Rita schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. the patient does not have a colostomy. the patient has several small abdominal incisions and a clear dressing over each site. the incisions are well approximated and the staples are dry and intact. there is a jackson-pratt drain intact with minimal serous sanguineous drainage present. the patient has a salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. the patient has no bowel sounds. the foley catheter has a small amount of dark amber-colored urine without sediments. the patient has sequential compression device (scd) in place. the nurse performs an assessment and that the patient's breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. the patient's cardiac assessment is within normal limits. the patient is receiving o2 at 2 l per nasal hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. the patient is confused as to place and time. cannula with a pulse oximetry reading of 95%. the vital signs include: blood pressure, 100/50 mm. a. explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed. b. what gerontological postoperative considerations should the nurse make?