M.M. arrives by wheelchair. As she transfers to the bed, what observations will you make? Why?

Question

Given the previous information, you can anticipate orders for M.M. Carefully review each
order to determine whether it is appropriate or inappropriate as written. If the order is
appropriate, mark it as A; if the order is inappropriate, mark it as I and change the order to
make it appropriate. Provide any other orders that might be appropriate for M.M.
1. Routine VS
2. Serum magnesium (Mg) STAT
3. Up ad lib
4. 10 g sodium (Na), low-fat diet
5. Change IV to a saline lock
6. Cardiac enzymes on admission and q8h × 24 hr, then daily every morning
7. CBC, BMP, and fasting lipid profile in morning
8. Schedule for abdominal CT scan for am
9. Heparin 10,000 units subcut q8h
10. Docusate sodium (Colace) 100 mg/day PO
11. Ampicillin 250 mg IV piggyback q6h
12. Furosemide (Lasix) 200 mg IV push STAT
13. Nitroglycerin (NTG) 0.4 mg 1 SL q4h prn for chest pain
14. Schedule echocardiogram

Answer 1

• Before she gets out of the wheelchair, ask her if she can stand to transfer to the bed, and observe
her ability to communicate, general skin color, respiratory rate and pattern, and balance and
coordination (safety issues for ambulation and self-care). In addition, you will be able to assess her
general hygiene status.
• Place your hands on the patient's skin to note temperature, turgor, and moisture on the skin; this
can be done while obtaining initial vital signs (VS).
• Observe the following as she moves from the wheelchair to the bed: gait, strength of arms and
legs, need for assistance, balance, coordination, effort, change in color, change in respiratory
pattern as she exerts herself. You can also check her feet for swelling as she transfers from the
wheelchair to the bed.

Answers:
2. A
3. I; activity should be up in chair/ambulate with assistance.
4. I; diet should be 2 g sodium (low sodium).
5. A
6. A
7. A
8. I; not necessary at this time.
9. I; dose should be 5000 units bid.
10. A
11. I; no current indication for antibiotic therapy.
12. I; 200 mg is too large a dose; a dose of 20 to 40 mg might be more appropriate.
13. I; dosage for sublingual (SL) NTG if chest pain is present is one tablet SL every 5 minutes, repeat
in 5 minutes × 2 if chest pain is not relieved, up to three tablets total. Call the staff on-call
physician if no relief after the first tablet; every 4 hours is an incorrect interval.
1. I; VS should be every 4 hours.
14. A
Missing orders:
• Obtain 12-lead electrocardiogram (ECG) to note any ischemic changes or rhythm problems. Specify
12-lead ECG.
• Potassium at 3.5 mEq/L. Potassium level is borderline low; should consider adding potassium to
the continuous IV solution or giving oral potassium supplementation.
• Based on serum magnesium results, magnesium supplementation might be required.
• Nonenteric aspirin (ASA) 325 mg PO should be given. The initial dose of ASA in the ER should be
325 mg, chewed. Thereafter, the usual dose is 81 mg PO daily.
• Thyroid-stimulating hormone (TSH). Subclinical hypothyroidism is now recognized as a risk factor
for heart failure (HF).
• Brain natriuretic peptide (BNP) might be ordered to check for HF.
• Oxygen therapy. Check Spo2 and administer oxygen as needed.