12/20/95

Phone Intake COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

Lydia Smith Nursing Notes

12/20/95

1730

2000

2200

2330

Admit note. 90 year female admitted from South Davis Hospital to room 311-2. Patient accompanied by several family members. Son signed all paperwork. Patient was at Lakeview hospital November 1995 due to sudden confusion, weak and incontinent. Increased fever with expressive aphasia. CT scan revealed hemorrhage. Patient placed in long term care where patient became severely agitated, combative. Patient calm during intake process. B. Hardy, RN

Patient up ambulating, banging on doors. Staff redirected several times. B. Hardy, RN

Patient out of bed, patient given nourishment. Speech garbled and intelligible (?) Patient responded to redirection with spitting, kicking and striking out. Ativan 1 mg intramuscularly given. B. Hardy, RN

Patient resting in bed, no distress noted. B. Hardy, RN

12/21/95 11 - 7 1515		Free text, nights. Slept well during night, no complaints when awake, moving about in bed, offered bathroom, refused. Diaper dry. Shelton CNA Behavior: Patient has been very aggressive towards staff. Patient has hit and kicked and scratched staff. Patient has not cooperated with staff's direction. Intervention - offer patient all meals and groups/ activities. Response - patient ate 100% of breakfast and 90% of lunch. Patient attended all groups and participated not very well. Plan - encourage patient to cooperate with staff's directions and continue to orient patient to surroundings. N. Hancock, CNA



12/21/95 1630 1700 1745 2145		Ativan 1 mg intramuscularly given, as patient spit out 1700 medication twice, hitting, pinching, kicking, banging at doors - increased elopement risk, and attempting to assist another patient from wheelchair despite staff asking her not to. Verbal redirection not effective. D. Kley, RN Patient sitting at table in day room with head resting on table, respirations even and unlabored Response to verbal stimuli - speech slurred, unintelligible. D. Kley, RN Patient alert, fed self. In day room watching video calmly. D. Kley, RN Behavior - patient has been very aggressive this shift. Patient has been undressing herself this shift. Patient has been hitting, spitting and kicking staff. Intervention - offered patient activities and meals. Response - patient did not attend activities, patient ate 55% of supper. Plan - observe and document activities. N. Beech, CNA



12/22/95 0130 1540		Patient agitated, up and down in bed assisted to bathroom. Voided quantity sufficient. Continued to be agitated. Ativan 1 mg intramuscularly given. Patient ambulated in hall with assistance and returned to bed. Currently resting quietly. T. Scholl, RN Behavior - patient has been very impatient and uncooperative with staff. Patient has continued to undress herself and has not talked to any staff or patients. Intervention - offered patient all groups/activities and meals. Response - patient ate 100 % of breakfast and 50% of lunch. Patient attended all groups and participated not very well. Plan - continue to encourage patient to interact more and not undress any more. N. Hancock, CNA

12/22/95

1900

2200

2230

2245

Lung sounds decreased in left lower lobe. D. Kley, RN

Ativan 1 mg given intramuscularly, right dorsal gluteal site as patient quite agitated. Hitting at staff, attempting to climb over siderails, disrupting roommate.

Patient has calmed down - in bed lying down, mumbling incoherently, no longer attempting to get out of bed without assistance. D. Kley, RN

Behavior - patient has been combative and physically aggressive towards staff this shift, (hitting, slapping, kicking, pinching, biting). Took her 1700 medications without combative response. Refused bedtime meds times 3 attempts. Confused. Does not participate in group. Continuously attempting to strip clothing. Intervention - attempted to administer medications as ordered. Provide groups. Verbal redirection as needed. Monitored/documented behaviors. PRN medications given as indicated. Response - patient does not respond to verbal redirection. Combative/assaultive towards staff this shift. Confused. Did not participate in group. Has stripped clothing continuously. Plan - redirect as needed. Medications as ordered. D. Kley, RN

12/23/95

0600

1300

Free Text: Patient slept throughout shift except when awakened for medication at 0200 and when assisted to bathroom at 0100, where patient voided. Patient remained continent for duration of shift. Patient took medication in applesauce without balking. L. Long, RN

(Mistaken entry, crossed out.)

Behavior - patient has been very abusive today. Patient has been spitting, pinching, digging and hitting staff. Patient has been undressing self all day. Patient has been uncooperative with staff. Intervention - offered patient activities of daily living group, and meals. (Continued on other side)

12/23/95

1300

1600

Med Note

1630

1700

Med Note

1830

1845

1500-2300

(Continued from other side) Response - patient needed maximal assist with activities of daily living. Patient attended group but was disruptive. Patient ate 70% of breakfast and 0% of lunch. Patient kept spitting out the food .Plan - follow care plan, redirect patient when aggressive. T. Sprague, CNA

Free text: Patient hitting, biting, kicking other patients and staff and trying to get up without assist. Patient medicated with Ativan 1 mg intramuscularly. L. Long, RN

Patient continues to try to get up without assist and tries to hit others. Patient restrained in chair with Posey belt; Dr. Weitzel notified. L. Long, RN

Patient continues to be combative, agitated, trying to get up, kicking at others. L. Long, RN

Patient still trying to stand without assist, mumbling angrily, spitting out food. L. Long, RN

Patient assisted to bathroom, calmed down and cooperated with bedtime cares. Posey removed, assisted to bed. L. Long, RN

Behavior - as above, then patient slept soundly for duration of shift. Intervention - meal, group, one-on-one, movie. Response - patient unable to track movie or group; unintelligible angry responses to all interactions. Plan - therapeutic, safe environment, medications as ordered. L. Long, RN

12/24/95

0100

Med Note

0200

0600

Free Text: Patient awoke and became increasingly agitated: yelling unintelligibly, trying to climb out of bed over side rail, throwing off bed clothes. Patient medicated with Ativan 1 mg intramuscularly. L. Long, RN

Patient with eyes closed, respiration even, unlabored. L. Long, RN

Free text. Patient has cried several times throughout the times of 2300 - 0700, patient finally fell asleep after midnight. Patient has been toileted. Patient has been resting well. S. Thomas, CNA

Behavior - patient has had episodes of agitation trying to bite and scratch staff Patient has been agitated, trying to pull out own self's hair. Patient has been alert and disoriented. Intervention - offered patient 1. Activities of daily living, 2. Group, 3. Meals. Response - Patient needs medium assist with activities of daily living, patient ate 40% of breakfast and 60% of lunch. Patient attended activities. Plan - follow care plan, redirect patient when aggressive. T. Sprague, CNA



12/24/95 1900 Posey on		Behavior - patient very aggressive, hitting staff, spitting at staff. Patient getting out of chair, laying on floor, refusing staff's assistance and redirection. Posey ordered to provide safety for patient and to prevent injury. Patient refused fluids. 2100 Patient offered fluids and medications. Patient spit at staff, clenched teeth, refused assistance with activities of daily living for evening. Patient was not cooperative. 2130 Patient in bed resting with eyes closed, Posey belt removed, will monitor with bed check and side rails. 2230 Patient checked for incontinence, diaper dry, patient remains quiet. Posey remains off with bed monitor and side rails for safety. Intervention - staff attempted to orient and redirect, encouraged to eat. Response - patient difficult to feed - hit staff. Would not respond to redirection. Quiet after Posey applied. Plan - monitor behavior and redirect before increase in agitation level. B. Hardy, RN

12/25/95
0645

1000

1100

1130

1200

Free Text: Patient has slept through shift. Patient up times 1 to toilet. S. Thomas, CNA

Free Text: Patient became agitated after breakfast, trying to get up without assist. Scratching and grabbing anyone within reach, trying to bite and kick others. Patient medicated with Ativan 1 mg intramuscularly and restrained with Posey belt. Conditions for release from restraint explained but patient too demented to acknowledge instructions. L. Long, RN

Patient remains agitated; trying to bite, scratch and kick others. L. Long, RN

Patient continues to refuse oral medication and tries to scratch or hit anyone who comes near. Patient medicated with Haldol 2 mg intramuscularly. L. Long, RN

Posey restraint removed, patient assisted to bathroom then to bed as she is calm and drowsy now. L. Long, RN

Behavior - Patient demented and agitated this shift, muttering angrily, refusing medications, trying to hit and kick staff and others,. as noted above. Intervention - offer group, movie, one-on-one, medications as ordered, restraints for patient safety. Response - patient ate 60% breakfast, (continued) L. Long, RN

12/25/95

NSG

(Continued) Day Shift Note: but 0% lunch as patient refused anything by mouth after 0900, spitting out anything she tasted, trying to scratch, bite, hit or kick anyone who came near. Patient calmed down after Haldol 2 mg intramuscularly then slept until change of shift. Plan – therapeutic, safe environment with medication as per Dr.’ orders. L. Long, RN

12/25/95 1945 PRN Meds		Behavior - patient throwing milk cartons at patients and staff. Attempting to bite staff, striking out at staff. Patient pulling arm of another patient. Not responding to staff's redirection. Spitting and grabbing at staff when they come within reaching distance. Ativan 1 mg given intramuscularly, three person assist to get patient positioned, patient tolerated procedure well. 2030 Patient refuses to take oral medication, slaps at nurse's hand, clenching teeth. Intramuscular Haldol 2 mg given per Doctor order if patient refuses oral medication. Patient placed in bed with 2 side rails up and bed monitor. Intervention - provided medications as ordered. Spoke in a calm, clear voice, maintained a safe distance. Reduced stimuli. Response - patient did not respond to interventions not involving medications. Patient decreased aggressive acts after injections. Plan - monitor and prevent escalation. B. Hardy, RN

12/26/96

0200

11 - 7

Patient agitated. Repeatedly attempting to get out of bed. To bathroom with assist. Ambulated in hall with assist. Striking out at staff, kicking. Throwing clothing. Ativan 1 mg intramuscularly given as ordered. T. Scholl, RN

Free text - Patient calmed after receiving Ativan. Appeared to sleep quietly remainder of night with respirations even and unlabored. T. Scholl, RN

Behavior - patient has had no aggressive behavior today. Patient has been sleepy and hard to arouse. Patient has been cooperative after breakfast. Intervention - offered patient activities of daily living group, meals. Response - patient needed medium assist with activities of daily living. Patient ate 0% of breakfast and 20% of lunch. Patient attended and participated in group. T. Sprague, CNA

12/26/95 2150		Behavior - patient showed very aggressive behavior this shift. Patient continued to undress herself, patient was also hitting, pinching and kicking. Also trying to bite staff and other patients. Intervention - patient was placed in a Geriatric chair, patient was redressed. Patient was also allowed to walk up and down hall while staff was watching her and helping her. Response-Patient became somewhat more combative. Plan - continue with medications per Doctor's orders, continue to observe patient's behavior, watch for any medication side effects. ? - CNA



12/27/95 11 - 7 900		Free text: Night. Slept well until 0200 then slept short intervals, restless, taking clothes and cover off. Once when up to bathroom, tried to sit on the floor, on return back to bed, continued restlessness and disoriented. D. Shelton, CNA Free text medication entry: Refused all medications, hitting and spitting at staff. Given Haldol 2 mg intramuscularly at 1000. Patient calm and took medications crushed in applesauce. S. Hansen, RN Behavior - patient was agitated in the morning then after Haldol was given patient calmed down. Patient was uncooperative with staff when staff tried to button up shirt. Patient has been drowsy after medications were given. Intervention - offer patient activities of daily living, meals, group. Response - patient needed maximum assist with activities of daily living. Patient ate 5% of breakfast and 40% of lunch. Patient attended group but was disruptive during group so patient had to leave group. Plan - follow care plan, redirect patient when agitated. T. Sprague, CNA



12/27/95 2145 2100 Medication note		Behavior - patient was calm until mealtime. After supper became increasingly agitated as time went on. Was scratching, hitting and generally physically abusive after family left in evening, refused evening medications. Intervention - RN medicated per Doctor's orders for agitation. Attended groups and ate 80% of dinner. Response - took oral medications after intramuscular medication intervention at which time the agitation gradually decreased. Was climbing out of bed for over an hour setting bed alarm off, but finally did relax and go to sleep. Plan - patient needs to take evening medications as ordered to keep behavior from escalating in the evenings. R. Huggins, CNA Late entry: Free text medication note. Patient refused evening medication plus was aggressive towards staff and agitated. Medicated with Haldol 2 mg intramuscularly as per Doctor's orders. One hour later at 2200 patient compliant with request that she take oral medication. L. Long, RN

12/28/95 11 - 7 1510		Free text: night. Slept fair. Up to bathroom twice, restless on return from bathroom for about an hour then slept remainder of night. No agitation when up. D. Shelton, CNA Behavior - patient has been stubborn and ornery during this shift. Patient has struck out at staff and has yelled and been disoriented. Intervention - offered patient all meals and groups/activities. Response - patient ate 100% of breakfast and 60% of lunch. Patient has attended a few activities, and did not participate in these. Plan - continue to encourage patient to not strike out and attend more groups. N. Hancock, CNA



12/28/95 2030 2145 2200		Haldol 2 mg intramuscularly as ordered as patient refused all bedtime oral medication. D. Kley, RN Haldol not effective - patient continuously attempting to get out of bed and Geriatric chair without assistance past hour. Biting, scratching, kicking. Posey in place, medical doctor aware. D. Kley, RN Behavior - Patient had been calm, quiet, clingy - wanting staff to stay by her, hold her hand all shift until bedtime in which patient became agitated. Refused bedtime medications.. Hitting, scratching, biting staff. Posey in place at this time. Patient continues to attempt to get out of bed. Attended group. Confused. Unaware of situation. Intervention - administer medications as ordered. Provided group. Provided quiet, structured, low stimuli environment. Allotted one-on-one time. Verbal limits given (ineffective). Reoriented as needed. Poseyed for her safety. Response - patient calm all shift until bedtime in which patient became agitated/assaultive. Confused. Unaware of situation. Attended group, refused bedtime medications - Haldol intramuscularly as ordered given. Plan - administer medications. D. Kley, RN



12/28/95 2200 Continued		(Continued) as ordered. Provide group, one-on-one group as needed. Redirection as needed. Provide quiet low stimuli structured environment. D. Kley, RN

12/29/95
12/28 - 2400

0415

0430

0530

0630

0900

Patient sleeping quietly in bed. Posey removed. Both side rails up. Bed check monitor in place. T. Scholl, RN

Patient up to bathroom with assist. Patient continent. Assisted back to bed - side rails up. Bed check remains in place. T. Scholl, RN

Patient found sitting on the floor by her bed. Bed check monitor malfunctioned. Patient combative, striking out, kicking, pulling at staff clothing. No bruising or reddened areas noted. Patient assisted back to bed. Posey belt on, side rails up, and bed check monitor in place. Nursing supervisor and head nurse notified. T Scholl, RN

Dr. Weitzel notified and order for Posey obtained. T. Scholl, RN

Posey off to allow patient movement - patient increasing agitation. Fluid and bathroom privileges offered. Posey back on. T. Scholl, RN

Med entry - patient refused medications - Haldol 2 mg given. S. Hansen, RN

12/29/95
0800

1000

1200

Patient in day room. Patient is in day room will not eat, hitting out at staff. Patient offered bathroom, circulation checked, Posey removed. Posey returned for fall risk and assaultive behavior - safety measures. S. Perry, CNA

Patient removed from Posey. Patient offered liquid, bathroom, and walked for circulation. Patient was agitated and physically aggressive to staff. Posey returned for patient safety. S. Perry, CNA

Patient offered lunch. Posey undone, patient walked to room with two staff assistants. Bathroom offered, liquids. Patient is agitated and physically aggressive to staff. Patient put in bed for rest, Posey returned for patient safety. S. Perry, CNA

Patient gotten out of Posey in bed, walked to bathroom, given liquids. Patient hitting staff. Patient returned to day room, Posey returned for patient safety. S. Perry, CNA

12/29/95
1500

1600

1800

Behavior - patient has been very confused and agitated today. Intervention - offered patient meals, groups, redirection. Response - patient ate 30% of meals. She will not let staff feed her and she only plays in her food. Patient was in group but is too confused to track groups. Patient was taken out of Posey every 2 hours. Plan - to continue to redirect patient when she becomes confused and agitated and starts hitting staff, and provide a safe environment. S. Perry, CNA

Patient is calm in Posey. No agitation at this time. L. Wilson, RN

Patient remains calm without agitation. Will remove Posey to evaluate patient=s tolerance. L. Wilson, RN

12/29/95		Behavior - for half the shift patient has been uncooperative and noncompliant. Posey was taken off at 1830. After Posey off patient was cooperative and compliant. No episodes of combativeness or aggressiveness. Intervention - all meals and medications, offered one-on-one with patient. Patient offered to walk and ambulate with assist. Response - patient is pleasant and cooperative last half of shift - ambulates in hall with assistance and is compliant with medications. Plan - continue with therapeutic environment and milieu, encourage and redirect when needed. M. Ward, RN

12/30/95 11 - 7 1610		Free text - patient up to bathroom with assistance 3 times in the night. Continent through the night. Otherwise appeared to sleep quietly. No agitation noted. Both side rails up. Bed check monitor in place. No problems noted. T. Scholl, RN Behavior - patient had no aggressive behavior this shift. Patient got up in morning and ambulated to bathroom to void. Eat breakfast without staff cueing. Patient did not grab at patients nor staff. Daughter in to visit, pleased with patient progress. Patient upset that daughter had a neck brace on and told daughter to remove brace. Patient requested paper and pencil to write. Patient set off door alarm once. Intervention - redirected patient from door - gave pencil and paper, provided activities of daily living. Response - patient did not write on paper` was easily redirected. Patient ate 100% with staff setup. Plan - observe behavior, redirect as needed. B. Hardy, RN

12/30/95 2200		Behavior - patient slept on and off most of afternoon. Took medications as ordered. Attended, but did not participate in group - confused. Became physically assaultive towards staff`at bedtime when assisting with evening cares. Up twice after in bed, now resting quietly with eyes closed. Respirations even and unlabored. Intervention - administered medications as ordered. Provided group. Reoriented.. One-on-one group time to promote socially appropriate behaviors. Provided a structured safe low stimuli environment. Response - patient took medications as ordered. Became assaultive towards staff during bedtime cares. Up twice, once in bed, then resting quietly. Confused. Plan - continue to administer medications as ordered. Verbally redirect/ reorient as needed. Provide groups. Provide a structured, safe, low stimuli environment. D. Kley, RN

12/31/95
11 - 7

1500

Night shift free text note. Patient rested quietly throughout most of shift. Awake once at 0300. Disoriented to person, place, time and situation. Oriented with soothing from nursing staff. L. Wilson, RN

Behavior - patient was agitated and aggressive at breakfast, taking clothes off and hitting at staff. Ate most of breakfast on own, spit out some of morning medications. Needed constant supervision in order to keep from harming self and others. Intervention - encouraged to eat breakfast and take pills. Encouraged to converse with nurse to help calm down, was about to medicate with Haldol 3 mg intramuscularly relative to didn=t take all medications. Patient fell asleep in chair in day room after breakfast, therefore did not give Haldol. Response - was calm after woke up from morning nap, more cooperative than has been past few days, interacted more with staff. Plan - continue to encourage food/ fluid intake. Encourage interaction with staff and group and to keep clothes on. J. Jensen, LPN

12/31/95 1500 - 2300		Behavior - patient attended group and movie but many times got up to wander. Patient was compliant with redirection and taking oral medications at dinner but as shift progressed became increasingly agitated: banging on exit doors, trying to slap CNA and RN, ranting in agitated tones her non-sensical objections to redirection or offer of food or water. Patient refused bedtime medications. Intervention - offered meal, snack, group, movie. Patient medicated with Haldol 3 mg intramuscularly per Doctor's as needed order. Response - patient ate 70% of dinner, 100% snack, and calmed down after Haldol, eventually taking bedtime medications. Plan - therapeutic safe environment, medications as ordered. L. Longs, RN

1/1/96

11 - 7

Night shift free text note: Patient rested quietly throughout the shift. Not roused by every 15 minute nursing checks. L. Wilson, RN

Medication note: Patient refused medications and was given 3 mg Haldol intramuscularly. Patient refused medications 1 hour after Haldol given. R. Clark, LPN

Medication note: patient medicated for escalating agitation at 1510 as evidenced by hitting other patients, pacing, rattling doors. R. Clark, LPN Behavior - patient was pacing much of morning. Little interaction. Angry affect. Intervention - meals, medications, groups, one-on-one time offered. Offered patient pen and paper for writing to distract from pacing. Response - patient aggressive when redirected, striking out, patient refused all oral medications and assistance with meals; patient only distracted momentarily with paper and pen. Plan - continue to try different methods to increase compliance with medications. R. Clark, RN

1/1/96		Behavior - patient was agitated and aggressive all shift, with no effects of 1500. Ativan noted as far as improvement in patient's mood. Patient refused all oral medications and any thing else offered, tried to punch staff, open exit doors. Intervention - patient medicated with Haldol 3 mg intramuscularly at 1700 due to refusal to take medications and general agitated behavior. Response - patient only calmed down at 2100 and compliantly took evening medications then, although patient was taking off her clothes in bed, muttering incoherently. Plan - therapeutic safe environment. L. Long, RN

1/2 /96 11 - 7 1400		Night shift free text note: Patient rested quietly most of shift. Awake once at 0400. Assisted to toilet. Returned to bed and remained quiet for rest of shift. L. Wilson, RN Behavior - Patient has taken her medications after much prompting by medication nurse. Intervention - support. One-on-one time. Limit setting. Response - oppositional, hitting and kicking at staff and other patients. Plan - medications as per doctor. Therapeutic environment. E. Cozzins, RN

1/2/96 3 - 11		Behavior - patient very drowsy during first half of shift, during second half patient agitated and refused medications by mouth. Family member tried to feed patient food. Patient still refused to open mouth for anything. No dinner eaten. Patient up ambulating in hallway with unsteady gait. Haldol 5 mg intramuscularly given per Dr. order when patient refuses oral Risperdol. Patient got out of bed 3 times. Undressed self and pulled gown up. Patient sleeping currently. Intervention - gave patient activity of daily living cares, attempted to give oral medication, provided as neede' medication, and redirected twice. Response - patient refused oral medications, would not respond to staff's redirection. Patient settled into bed at 2130. Plan - observe behavior, report findings to Doctor daily. B. Hardy, RN

1/3/96

11 - 7

1300

0800
Med note

Free text - patient very restless, sitting up in bed, restlessly attempting to get out of bed. Patient up ambulating in hall with assistance. Striking out, kicking at staff and attempting to step on staff. Intramuscular Haldol given as ordered for severe agitation. Patient slept quietly remainder of night, respirations even and unlabored. T. Scholl, RN

Behavior - patient refused morning medications. Patient has been very aggressive, hitting, kicking and biting staff. Patient very difficult to redirect. Intervention - support. One-on-one time. Intramuscular medications. Safe environment provided. Response - very aggressive and agitated. Pacing very confused. Not oriented to time, place or person. Plan - medications as per Doctor. Safe therapeutic environment. E. Cozzins, RN

Late entry, medication note: patient refused morning medications or anything by mouth (continued) L. Long, RN

1/3/96
Day shift notes,
Med note
con=t 0800
1000
Med note

1200
Med note

1300

(continued) plus was trying to hit and spit at staff and other patients. Patient medicated with Haldol 5 mg intramuscularly. L. Long, RN

Free text: patient still refusing medication or anything offered by staff, in demented, disoriented fashion, muttering incoherently but automatically trying to slap away hand of staff. No discernable decrease in agitation since Haldol intramuscularly. L. Long, RN

Free text: patient's agitation increasing: hitting, biting, kicking, spitting at staff and other patients. Patient medicated with Ativan 2 mg intramuscularly, with immediate results: patient calm, not agitated or aggressive. L. Long, RN

Free text - patient took morning medications without complaint. L. Long, RN

1/3/96 2245		Behavior - patient very drowsy in Geriatric chair at start of shift. Patient did not eat dinner due to lethargic state. Patient placed in bed. When taken to bathroom, patient would pick up both legs and bend them. Staff had to support for entire ambulation transaction. Intervention - gave Haldol intramuscularly due to patient not taking medications by mouth, provided evening care and assistance with all cares. Response - Patient would not allow any oral medications. Patient clamped teeth shut and attempted to grab at staff. Patient got out of bed twice, sitting on edge, and would not ambulate with staff assistance to bathroom. Defiant of staff's efforts displayed by raising legs while ambulating. Plan - moniter effects of intramuscular Haldol. B. Hardy RN Med Note: Patient given Haldol 5 mg intramuscularly when medications refused per Doctor's order. R. Clark LPN



1/4/96 0445 0600 11 - 7		Medication note - patient restless, tossing and turning. Up to bathroom, biting at staff, striking out and kicking. Returned to bed and intramuscular Ativan given as ordered. T. Scholl, RN Patient calmer but continues to have difficulty sleeping. T. Scholl, RN Free text - patient appears to be sleeping quietly since 0630. Side rails up bed check in place. T. Scholl, RN Behavior - patient has been lethargic during the shift. Patient has been nonresponsive to staff. Patient has been sleeping all shift. Intervention - offered patient activities of daily living, group, meals. Response - patient needed maximum assist with activities of daily living. Patient ate 0% of meals, because patient would not arouse to meals. Patient attended group but slept through group. Plan - follow care plan, encourage patient to stay awake and eat meals. T. Sprague, CNA

1/4/96 2220		Behavior - patient has been quiet this shift, dozing on and off. No physical aggression towards staff this shift. Refused 1700 medications. Took bedtime medications except Depakene syrup. Did not participate in group. Intervention - administered medications as ordered. Provided group. Monitored behavior. Response - patient quiet this shift. Dozed on and off. No episodes of physical aggression noted toward staff. Refused 1700 medications, took most of her bedtime medications. Went to bed with assistance from staff without problems. Did not participate in group. Plan - continue to administer medications as ordered. Provide group. Monitor behaviors. Encourage socially appropriate behaviors - redirect as needed. D. Kley, RN

1/5/96
0130

0230

0700

7 - 3

Medication entry - patient very agitated, making numerous attempts to get out of bed. Striking at staff. Resisting assist to bathroom. Haldol 1 mg intramuscular given for severe agitation. T. Scholl, RN

Patient has been sleeping quietly since 0145. Respirations even and unlabored. Both side rails up. Bed check monitor in place. T. Scholl, RN

Patient continued to toss and turn but less restless and did sleep for short periods of time. T. Scholl, RN

Behavior - patient very lethargic this shift, sitting with eyes closed, trying to remove clothing, socks; batting away any offered snack or beverage, mumbling incoherently. Intervention - offered group, one-on-one, assistance with all activities of daily living. Response - patient unresponsive verbally and hit out whenever cares given, food offered. Plan - therapeutic safe environment, medications as ordered. L. Long, RN



1/5/96 3 - 11		Problem: Altered thought process. Behavior - patient up in recliner chair most of shift. To bed at 8 pm. No verbal responses. Patient is awake, level of alertness waxes and wanes. Respiration rate: slow, deep and regular. Vital signs stable. Afebrile. Took oral medications with difficulty at 1700 and 2100. Pills crushed in orange sherbet. Tolerated okay. Depakene suspension via syringe very slowly. "Spit up" slightly after 2100. Depakene dose. Other bedtime medications in sherbet tolerated well. Intervention - observe and document behavior. Assist patient to take medications as ordered. Provide safe environment. Monitor medication effects. Response- patient does not appear to tolerate liquid Depakene very well. (Will notify medical doctor). Remains somnolent and avoidant of physical contact. Reflexive manner of combative behavior. Positive snout reflex. Plan - continue current interventions as specified above. L. Wilson, RN

1/6/96 11 - 7 1415		Free text - patient awakened once during the night - attempting to remove diaper. Taken to bathroom on potty chair - voided. Continent through the night. Patient returned to bed and slept quietly remainder of night. No problems noted. T. Scholl, RN Behavior - patient has not been agressive. She has been sleeping most of day. When awake she has kept trying to strip. When offered meals she has spit it out at us. Intervention - offer groups and meals. Response - patient slept through most everything. Plan - continue to offer group and meals. Angie Kennedy, CNA

1/6/96 2130		Behavior - patient has been quiet this shift. Rested quietly with eyes closed most of shift, respirations even and unlabored. Ate none of supper. No episodes of combativeness. Took medications as ordered. Intervention - administer medications as ordered. Provide group. Monitored behaviors. Response - patient appeared to sleep most of this shift as evidenced by resting quietly with eyes closed, respirations even and unlabored. Slept in chair at supper, ate nothing, took medications as ordered Did not interact in group. No combative episodes this shift. Plan - continue to administer medications as ordered. Provide groups. Monitored behaviors condition. Reorient. Redirection as needed. D. Kley, RN

1/7/96 11 - 7 1400		Night shift free text. Patient rested quietly throughout shift. Minimally responsive to morning cares (bed scale weight, vital signs, diaper change). Respirations slow, deep and regular. Keeps eyes closed most of the time. No combative behavior. Posture is rigid at times. L. Wilson, RN Behavior - patient not able to take medications. Patient lethargic and unresponsive. Patient not swallowing or responding to staff. Intervention - patient=s family notified of patient's condition. Family in to be with patient. Oral care given. Doctor called (unknown word) twice without calling back. Response - no wet diapers. No oral intake. Plan - turn every 2 hours. Good activity of daily living care. Follow Doctor's orders. E. Cozzins, RN

1/7/96 2200		Behavior - patient not able to take any medications. Patient unresponsive most of the shift. Intervention - support. One-on-one time. Medications as per Doctor. Family and Doctor notified of patient's condition. Response - family and Dr. Weitzel in to see patient. Respirations shallow. Plan - comfort measures. E. Cozzins, RN

1/8/96
11 - 7

1200

1245

Night shift free text note. Patient lying in bed with eyes open throughout shift. Demonstrates much reflexive grasping in response to physical stimuli. Unable to make any verbal response. Morphine sulfate every 3 hours intramuscularly as scheduled for comfort. 2400 dose omitted due to patient appeared in no acute distress at the time and nursing staff was attending another dying patient and her family. 0300 dose given at 0230. Respiration rate 10 to 12. Apneic periods from 10 to 20 seconds. Long period Cheyne-Stokes respirations. After 0500 respirations 14 to 16, slow, deep and regular, without waxing and waning pattern. L. Willson, RN

Respiration relaxed. Daughter at bedside. Skin pale. L. Willson, RN

Patient's daughter requested us to check patient. States "I don't think she is breathing." Patient checked. No respirations. No pulse. Patient placed on her back with hands to side, teeth placed in mouth. ? RN

1/8/96 1245 1255 1330 1430 1350		Emergency room Doctor notified to pronounce patient dead. Nursing supervisor notified. Daughter notified. ? RN Dr. Weitzel notified by phone of patient death. ? RN Nursing gathering up patient items. Family given all of patient's things. Waiting for mortuary to come and take patient. Patient has been cleaned up. Diaper changed. Daughter and son in room. ? RN Patient taken out via gurney with Allen Hall Mortuary. Family took all belongings home. ? RN Late entry. Emergency room Doctor came to officially pronounce patient dead. ? RN

Psych Eval History & Physical Discharge Summary

Living Will / Medical Treatment Plan

Physician's Orders Progress Notes Nursing Staff Notes

<< Back To Home Page