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Lydia Smith  Progress Notes
12/21/95
Occupational Therapy		   Occupational therapy initial evaluation completed. Structured interview attempted. Patient unable to communicate with therapist at this time. J.V...? COTA/L
     
12/21/95
MD 		   Psychiatric evaluation done and dictated. Has urinary tract infection. Quite demented. Plan: Risperdol and Serzone. Treat urinary tract infection. Robert Weitzel, M.D.
     
12/22/95
Occupational Therapy 		   Unable to complete structured interview secondary to impaired attention span and cognition level. J.V...? COTA
     
12/22/95
Social Services		   Social Work Note: Patient unable to complete CQI scales due to cognitive level of functioning. K.Steglich, CSW
     
12/22/95
Social Services		   Social Work Note: Contacted patient's son, Kent Smith, and obtained pertinent information to complete psychosocial assessment. Family extremely supportive.Son informed clinical social worker that patient progressively gotten to the point where she had to have a family member physically near her or she would become combative and agressive. Briefly discussed possible discharge options. Son identified Rocky Mountain Care, Bountiful or South Davis. K. Steglich, CSW
     
12/22/95
Social Service		   Social Work Note: Patient's psychosocial assessment completed.
K. Steglich, CSW
     
12/22/95
MD		   Stable. Vital signs stable, afebrile. Pretty lethargic. Assessment - major depressive disorder with psychotic features. Plan - Serzone and Risperdol. Robert Weitzel, M.D.
     
12/23/95
MD		   Vital signs stable, afebrile. Much less lethargic. Very demented. Digoxin level OK. . Thyroid function tests normal. Despite pyuria, urine culture reveals no pathogens. Assessment - tolerating medications well. Plan - Continue current care. Robert Weitzel, M.D.
     
12/24/95
Nursing		   Weekly nursing note: Patient has agitated, angry, aggressive periods every day, usually requiring PRN medications or restraint. Speech is unintelligible but tone is angry, exasperated. Patient often refuses medications spitting out pills or slapping hands of staff. Patient often spits food at staff or onto floor, often refused proffered food or drink, muttering "I don't need," or other garbled negative sounding declinations. Continue current care. L. Long, RN
     
12/24/95 
MD		   Needed a lot of Ativan last night. Striking out still. Seems to sundown badly. Vital signs stable, afebrile. Assessment - stable. Plan - Trazodone, routine and PRN. Robert Weitzel, M.D.
     
12/25/95
MD		   Didn=t need Posey last night, and has been continent today through night. Apparently calms quite nicely when her family is around, but can be very aggressive/ negative later. Tolerating medications well. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D.
     
12/26/95
MD		   Does pretty well with some Haldol; without major extrapyramidal symptoms. Can be quite aggressive, and is very demented and primitive. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D.
     
12/27/95
MD		   Continues to be aggressive and psychotic. Vital signs stable, afebrile. Very demented, mood dysphoric. Assessment - major depressive disorder with psychotic features. Plan - continue current care. Robert Weitzel, M.D.
     
12/28/95
 

Dietary

   Nutrition Update: Weight is 115.6 lbs. Admission weight 116 lbs. Patient's oral intake varies greatly from 0 to 100 percent. Patient refuses some trays and spits out food when agitated. Plan - will continue to offer 3 meals daily and bedtime snack. Will monitor intake and changes in weight. R. Warner, Nutritionist
     
12/28/95
OT		   Occupational Therapy Weekly Note: Patient requires multiple verbal cues to arouse. Once aroused, patient is preoccupied with unbuttoning (error) doffing shirt. Patient continues to require cueing to redirect to task, patient demonstrates increased frustration when aroused and requires redirection with minimal assist. J.V. COTA/L
     
12/28/95
MD		   Doing better, much less irritable, has hit no one today. Vital signs stable, afebrile. Quite demented. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D.
     
12/28/95
(Late Entry - 
12/27/95)
Family Therapy		   Social Work Note: Spoke with patient's son and daughter who is from Arizona. Discussed patient=s progress. Family verbalized concern regarding discharge plans. They emphasized importance of decrease in patient's aggressive behavior if she is to be admitted to Rocky Mountain Bountiful after discharge. Provided supportive counseling. Family conference to be arranged next week to discuss discharge plans in detail. K. Steglich, CSW
     
12/29/95
MD		   Once again is irritable today, has been hitting out again. Very demented. Spoke with her daughter regarding therapy and prognosis. Vital signs stable. Afebrile. Assessment - intermittently quite aggressive, this would block placement. Plan - Depakene. Increase Haldol intramuscularly when and if Risperdol refused. Haldol as needed. Robert Weitzel, M.D.
     
12/29/95
Social Services		   Weekly progress summary - Social Work: Patient has attended group therapy. Patient had to be removed from group times 2 due to disruptive behavior. Patient has not participated in group even with one-on-one cues. Patient alert but confused and disoriented. Patient continues to be agressive and combative with staff, refusing to take medication. Kicking, spitting. Will continue with master treatment plan. K. Steglich, CSW
     
12/30/95
MD		   Very variable behavior. Daughter's here to visit, we talked briefly. Getting about half of her anti-psychotic (medication) via intramuscular Haldol until today, when she took oral Risperdol; and behavior has been good today. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D. 
     
12/31/95
MD		   Taking medications all right.Vital signs stable. Afebrile. Slept through the night. Mildly lethargic, arouses easily. Eating well. Assessment - stable. Plan - continue current medications. Robert Weitzel, M.D. 
     
1/1/96
MD		   Slept through the night. Has been refusing medications again and was quite recalcitrant, got aggressive this evening and received Ativan intramuscularly, which helped. Vital signs stable. Afebrile. Assessment - remains labile and intermittently agressive. Plan - increased Depakene. Robert Weitzel, M.D.
     
1/2/96
Nursing		   Weekly RN advocate note: Patient has persisted in her refusal to take medications. She has required many doses of intramuscular Haldol as a result. Her aggressive behavior continues. Her behavioral (continued) (L. Wilson RN)
     
1/2/96
Nursing		   (continued) goals have not been met. L. Wilson, RN
     
1/2/96
MD		   Disoriented, confused, demented. Did sleep through night after a difficult evening. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care Risperdol (error) Haldol ordered increased. Robert Weitzel, M.D.
     
1/3/96
MD		   Apparently misses many doses of her medication secondary to noncompliance, then is mildly labile and irritable. Vital signs stable, afebrile. Assessment - Still quite dysphoric and intermittently psychotic. Plan - Increased Serzone, add Trazodone in daytime, Clonidine patch might help. Thanks, Robert Weitzel, M.D.
     
1/4/96
MD		   Remains recalcitrant. Climbing out of bed in early morning, virtually entangled in bed rails. Very poor judgment. Vital signs stable, afebrile. Assessment - remains symptomatic. Plan - observe on increased Serzone/ Trazodone, added Clonidine. Robert Weitzel, M.D.
     
1/4/96
OT		   Occupational therapy weekly summary: Patient attends occupational therapy group sessions, patient unable to participate secondary to her being preoccupied with doffing clothes. Patient requires to require verbal cues with moderate assist to arouse and attend. Patient continues to demonstrate increased frustration and increased agitation when aroused. J.V. ...? COTA/L
     
1/5/96
MD		   Very obstinate, angry. Vital signs stable. Afebrile. Very demented. On Depakene, Clonidine, Serzone, Risperdol, Trazodone; but continues to be very negative. Taking medication today. Assessment - stable. Plan - continue current care. R. Weitzel, M.D. 
     
     
     
1/5/96
Individual Therapy		   Social work progress note: Attempted one-on-one therapy with patient. Patient non-responsive, therapist attempted to arouse times 3. Patient had minimal response. Will continue to try and engage patient in one-on-one therapy. K. Steglich, CSW
     
1/6/96   Nutrition Update: No new weight or labs. Patient intake continues to vary, generally very poor, 0 to 40 percent. Patient spits out food. Continue to offer 3 meals and bedtime snack. Would like to assess current weight status. Toni Anderson, RD
     
1/6/96
Social Services		   Late entry for 1/5/95 Social Work Weekly Summary - Patient has not attended group therapy or participated in individual therapy due to lethargy. When attempts are made to arouse patient she displays minimal responses. Patient continues to refuse to take medications. Patient consistently tries to remove clothes and continues to be aggressive and agitated with staff. Patient confused, disoriented, and when she does communicate she mumbles incoherently. Family involved in discharge planning. K. Steglich, CSW
     
1/6/96
Family Therapy		   Social Work Note: Spoke with patient's daughter, Bonnie, via phone. Provided her with education regarding potential nursing homes for patient after discharge from hospital. Addressed her questions and concerns related to nursing home placement. Met with patient's son Kent and his wife and discussed patient's status. He verbalized concerns about patient's physical status. Encouraged him to contact Dr. Weitzel Monday morning to discuss patient's medical status. 
     
1/6/96
Family Therapy		   Social Work Note Continued - Kent very realistic about patient's declining mental status. Provided supportive counseling. Educated him regarding potential nursing home options. Scheduled tentative family conference for 1/10/96 to review patient's progress and confirm patient's disposition after discharge from Geropsych unit. K. Steglich, CSW
     
1/6/96
MD		   Feeding poorly, lethargic. Ambulating a bit Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D.
     
1/7/96
MD		   Very weak, not taking any nourishment, no urine output. Family discussion with 2 sons and daughter reveals that they don't want her life prolonged, but are ready to let her go. At times she thrashes about, seems to be in pain/anxiety. Assessment - quite ill. Plan - hold medications, morphine sulfate 5 mg every 3 hours intramuscularly. Robert Weitzel, M.D.
     
1/8/96
Nursing		   Weekly Rn Advocate Note: Patient's physical condition has markedly deteriorated. She is unable to swallow food, fluid or medication. She's not visually responsive to her environment. She demonstrates some regressed reflexes: reflexive grabbing, positive snout reflex. Pupils are minimally reactive to light. Periodically she demonstrates Cheyne-Stokes respirations (rate 10-12). She is receiving Morphine sulfate 5 mg every 3 hours for comfort. The care plan has been changed to reflect patient and family needs around death and dying issues. L. Wilson, RN 
     
     
     
1/8/96
MD		   Patient remains unresponsive. Takes no fluids. Her vital signs remain strong; she is afebrile. Assessment - probably terminal. Plan - increase Morphine sulfate, she is occasionally appearing to be in discomfort. Robert Weitzel, M.D.
     
1/8/96
OT		   Occupational Therapy Discharge Summary Note: Patient was unable to attend OT daily group sessions this week secondary to unresponsiveness and decreased arousal. J.V... ? COTA /L
     
1/8/96
Family Therapy		   Social Work Note - Met with patient's daughter-in-law, granddaughter and daughter. Provided bereavement and grief counseling. Discussed grief issues and provided support. K. Steglich, CSW
     
 

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