CASE STUDY OF MRS.

WALKER
 Captopril
Right medication Diagnosis: Patient has a primary
and Right reason medical diagnosis for type Hypertension
related to coronary artery disease.
The mechanism of action: Lowering of
BP in hypertensive patients. Improved
symptoms
vasodilation(Vallerand.H,2019,p.164)
Pharmacological class: ACE inhibitors
Right dose Calculations: 25mg/12.5mg*1Tablet =
2 Tablets
Safe dose: Yes, 25mg PO (orally) 2-3
times a daily is a safe dose
(Vallerand.H,2019,p.165)
Right Time Patient should administer 25mg PO
(orally) 1 hr or 2 hr after meals.
Right Route PO is an orally route, so medication
should be taken by mouth.
Right Patient For verification purposes, I will check
patient’s ID band to confirm the name
and date of birth. I will proceed by
verifying the physician order with MAR.
Right Documentation should be done after the
documentation administering the medication and after
the evaluation
Right assessment Pre-assessement : I will start my
assessment with taking vital signs and
check LOC of the patient. Ask for any
allergies and assess the ability of
swallowing. Assess patient for signs of
angioedema (swelling of face,
extremities, eyes, lips, tongue, difficulty
in swallowing or breathing) may occur
at any time during therapy.
Post-assessment : I will start my post
assessment with taking vital signs again
and ask for cough or taste
disturbances to make sure that
Medication is working and will check
for no adverse effect or allergic reaction
for the patient.
Levothyroxine (Eltroxin)
Diagnosis: Patient has a secondary
medical diagnosis for
Hypothyroidism.
The mechanism of action:
Replacement in hypothyroidism to
restore normal hormonal balance.
Suppression of thyroid
cancer(Vallerand.H,2019,p.769)
Pharmacological Class: Thyroid
preparation.
Calculations :
75mcg/50mcg*1Tablet = 1.5Tablets
Safe dose : Yes, 75mcg PO (orally)
once in day is a safe dose
(Vallerand.H,2019,p.770)
Patient should administer 75mcg PO
(orally) daily with a full glass of
water, on an empty stomach, 30-60
min before breakfast, to prevent
insomnia.
PO is an orally route, so medication
should be taken by mouth before
breakfast
For verification purposes, I will
check patient’s ID band to confirm
the name and date of birth. I will
proceed by verifying the physician
order with MAR.
Documentation should be done after
the administering the medication and
after the evaluation.
Pre-assessment : I will start my pre-
assessment with by taking vitals
signs (respiration rate, pulse, blood
pressure, oxygen saturation,
temperature) along with this I will
assess apical pulse. I will also check
patient’s LOC along with assessing
the ability of swallowing. Assess for
tachyarrhythmias and chest pain.
Post-assessment: I will start by
taking vital signs and ask for any
chest pain, to make sure that
medication is working and has no
adverse effect or allergic reaction for
the patient.
Right patient Encourage patient to comply with
education additional interventions for hypertension
(weight reduction, low sodium diet,
discontinuation of smoking, moderation
of alcohol consumption, regular
exercise, and stress management).
Medication controls but does not cure
hypertension. Instruct patient and family
on correct technique for monitoring BP.
Advise them to check BP at least
weekly and to report significant changes
to health care
professional(Vallerand.H,2019,p.
Right to refuse Mrs. Walker refused to take Captopril
because when she administers medicine
it makes her cough.
NANDA DIAGONSIS BASED ON REFUSAL
Diagnosis statement Outcome
Instruct patient to take medication as
directed at the same time each day.
Take missed doses as soon as
remembered unless almost time for
next dose. If more than 2– 3 doses
are missed, notify health care
professional. Do not discontinue
without consulting health care
professional (Vallerand.H,2019,p.
I will ask the patient if there is any
issue or concern that I have to
consider before giving this
medication and Mrs. Walker express
no problem to administer
levothyroxine.
Intervention