Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

• Heart rate 96 beats/minute
• Blood pressure 90/62 mm Hg
• IV infusing at 125 ml/hr
• Respirations 16 breaths/minute

Respiratory

• Oxygen saturation of 89%
• Several deep breaths

Integumentary

• Episiotomy intact with no redness
• Pad is saturated with blood
• 18 gauge IV to left forearm

Genital/Urinary

• Boggy fundus 1 cm above umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Rationale

A. Older adults are more susceptible to medication side effects due to changes in metabolism and polypharmacy. Reviewing the client's current medications, including over-the-counter medications for allergies and insomnia, can identify potential culprits.

B. Some medications used for allergies or insomnia, such as antihistamines or sedatives, can cause EPS in older adults. EPS include symptoms like tremors, rigidity, or involuntary movements. These symptoms can indicate adverse reactions that require immediate attention and adjustment of medication.

C. These symptoms could be side effects of medications commonly used for allergies and insomnia. They may also indicate other underlying health issues or medication interactions. Assessing these symptoms helps in determining their severity and whether they require further evaluation or intervention.

D. Social isolation can contribute to changes in behavior, especially in older adults. While social activities are beneficial for mental health, in this case, addressing the potential medication-related issues (options A and B) takes precedence to ensure the client's safety and well-being.

Rationale

A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.

B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.

C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.

D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.