12/28/95

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

Mary Crane Nursing Staff Notes

12/28/95 1800		PRN medication given: Tylenol 650 mg by mouth given as ordered as patient complains of headache. D. Kley, RN

2000		Tylenol helpful. Patient complains of "still have headache, but it's better." D. Kley, RN

1600		Admission note. Behavior. Patient admitted to Geropsychiatry with diagnosis of depression with psychotic features. Long history of depression and psychiatric interventions. Has worked as LPN until death of her husband, then unable to cope with the stress. Comes to us from care center, where she has been biting, kicking, and verbally abusing staff. History of hyponatremia - craves fluids enough to drink from toilets when fluids are restricted. Has had seizure secondary to hyponatremia "in the past". Intervention - oriented patient and family to unit layout and policies. Completed admission assessment. Belongings inventoried.. 1800 calorie ADA diet provided. Duragesic patch instituted for chronic back pain due to old disc injury. Response - patient calmer, more quiet in late evening. (earlier yelling quite a bit). Does eventually respond to comfort measures. Plan- see treatment plan. L. Wilson, RN

12/29/95 0615		Free text: Patient slept all shift, until she was awakened for her chest x-ray. No problems noted this shift. ?CNA

0800		Duragesic patch came off. New Duragesic applied. S. Hansen, RN

1540		Behavior. Patient has continually asked for fluids and to go to her room and lie down. Patient has been confused and has not been able to figure out where she is or what she should be doing. Intervention - offered patient all meals and Agroups/ activities. Response - patient ate 100% of all meals. Patient attended groups, but did not participate. Plan continues to encourage patient to interact more and focus on the activities. N. Hancock, CNA

12/29/95 2220		Behavior - Patient has been consistent in requesting fluids non-stop and requesting that she go to her room to lie down. Patient is confused and most of the time disoriented. Intervention - one-on-one with patient. Meals and medications are offered. Response - patient ate most of meals and was compliant with medication. Patient continued to ask for fluids and for her room. Plan - continue with therapeutic environment. Provide redirection and encouragement when needed. D. Kley, RN

12/30/95		Free text. Patient awake approximately first 45 minutes of shift. Patient incontinent x 2. Complete bed change once. Patient appeared to be resting. Ables

1230	Patient complains of pain "all over," medicated with Tylenol, 2 tablets by mouth. J. Jensen, LPN

1500	Behavior - patient has been in a flat mood today. Patient does not talk much; she just stares into space. When patient does talk she screams constantly. Intervention - offered patient meals, groups, and redirection. Response - patient ate 100% of breakfast and 80% of lunch. Patient attended groups but does not track. Patient needed redirection when she yelled out in the afternoon. Plan - to continue to redirect patient when she gets agitated and lethargic. Perry, CNA

12/30/95 1600		Respirations as though snoring, however; eyes wide open. Does not answer questions. No verbal responses. D. Kley, RN

2140		Behavior - patient quiet, nonverbal, first half of shift. Staring gaze. Would turn gaze slowly towards speaker without verbal response. Ate 80% of supper. Began to yell for help after supper. When asked what she needed, stated "I don't know." Had one medium green diarrhea stool this shift. Took medications as ordered. Has not displayed any verbal or physical abusiveness towards staff. Intervention - administered medications as ordered. Provided group. Monitored behaviors. Provided low stimuli environment. Response- patient did not participate in group. Was not responding verbally - was physically present. Took medications as ordered. Displayed no verbal or physical abusiveness towards staff. Plan - continue to administer medications as ordered. Provide a safe, low stimuli environment. Provide groups and one-on-one time as needed. D. Kley, RN

12/31/95 11 - 7		Night shift free text note. Patient has been awake most of shift. At 2 a.m. Trazodone 100 mg prn and Tylenol 2 tablets given for sleep and discomfort respectively. Patient able to rest quietly until 6 a.m. after medication was given. L. Wilson, RN

1030		Patient very drowsy not able to stay awake. B. Hardy, RN Behavior - patient has been very drowsy and hard to arouse today. Patient has been cooperative with staff when awake. Patient has been asleep in hall most of day. Intervention - offered patient activities of daily living cares, meals, one-to-one. Response- patient needed maximum assist with activities of daily living. Patient ate 100% of breakfast and 30% of lunch. Patient has not been interacting with peers. Plan - follow care plan. Encourage patient to stay awake. T. Sprague, CNA

12/31/95 1625		Behavior - patient has been up in chair this evening with some aggressive behavior towards staff. Patient would cry out "help me" but patient would not state what help was needed. Intervention - offered patient group, one-on-one, meal. Response - patient attended group, ate 50% of meal. Patient would reach for peers food but hardly ate any of her own. Plan - continue to follow care plan, and offer therapeutic environment. Unknown writer

1625-2300 Med Note		Free text: Patient was increasing agitated from 7 p.m. on; screaming, trying to hit, biting CNA. Doctor notified, patient medicated with Ativan 2 mg intramuscularly with good results; patient settled down and agreed to take her evening medications. L. Long, RN

1/1/96 11-7		Free text night shift - Patient rested quietly until 0500. Patient woke up and started moaning and wailing - when asked what was wrong, patient just stared at staff and wouldn't say anything. Patient was incontinent of urine twice. N. Hancock, CNA

1100		Behavior - patient had large soft greenish stool on toilet with staff assist. (B. Hardy,RN)

1130		Patient had another stool in diaper while in Geriatric chair. When cleaning peri area, staff nurse observed bowel movement coming from vagina. Area cleansed and fissure was noted. Doctors notified. B. Hardy, RN

1200		Doctor Dienhart in to see patient, received orders for CBC with differential and gynecology consult. Decreased Duragesic patch to 25 mcg. B. Hardy, RN

1430		Behavior - patient very resistant to staff's efforts to perform activities of daily living. Patient kicking, biting staff's fingers when placing dentures in mouth. Patient would not stay placed in wheelchair, keep sliding down, grabbed other patient's meal trays (continued) B. Hardy, RN

1/1/96 1430		(continued) Patient would not bear weight for transfers, continues to say "let me up." Intervention - Staff attempted to allow patient to stand. Provided activities of daily living and set boundaries for touching other patient's trays. Response - patient would not bear any weight on feet, continued to grab others trays. Plan - followup with gynecology consult in morning, followup book annotated. B. Hardy, RN

2210		Behavior - patient was physically and verbally abusive to staff this shift. Patient continued to hit, kick and try to bite staff members. Not easily redirectable. Intervention - tried to provide a safe environment for patient. Response - patient's response was very negative. Plan - continue with groups and medications per Doctor's order. Continue to follow care plans. (Ables, CNA

1/02/96 11-7		Free text - night shift. Patient rested well all night, did not get up or make any complaints. N. Hancock, CNA

		Behavior - patient has been hitting, throwing food tray on floor and kicking staff. Patient has been uncooperative with staff. Patient has been alert and disoriented. Intervention - offered patient Activities of daily living group, meal. Response - patient needed maximum assistance with Activities of daily living. Patient attended group and participated. Patient ate 60% of breakfast and none of lunch. Plan - follow care plan, redirect patient when agitated. T. Sprague, CNA

1/02/96 2100		(Mistaken entry, crossed out)

2110		Problem 1: - Behavior - patient has been very socially inappropriate. Patient has been hitting, biting, verbally aggressive at times. Patient is not cooperative with staff. Intervention - patient was offered medication, group, meals, snacks, fluids. Response - patient did not participate, however patient was not disruptive. Patient did eat well at dinner. Patient became very stubborn when she wanted to go to bed. Patient was told it wasn't time, patient forced herself in her room. Plan - patient needs to cooperate with staff. Patient needs to participate in group. Patient needs redirection when inappropriate. S. Thomas, CNA

1/03/96 11-7		Free text night: Snored all night with eyes open. Oxygen 1 2 liters nasal cannula color pale, skin warm and dry, no response. Temperature elevated, RN attempted to give Tylenol, unable to get her to take. Up and diaper changed once. Accuchex 178. D. Shelton, CNA

0950 Med Note		Sleep well, calm in morning, agitated in afternoon, when going to bed. A.M. care complete. Hit out at the nurse. Intervention - offered group and fluid but was agitated with food. Response - became agitated in group, tried to calm patient. Plan - treat patient with medications and one-on-one care.

1130		Late entry: Patient crying out in group, groaning, yelling, grimacing. Dr. Weitzel called: patient subsequently medicated with Morphine sulfate 3 mg intramuscularly per Doctor's orders. L. Long, RN

1/03/95 1200 Med Note		Day shift notes continued. Free text; late entry: patient was calm after lunch, took a nap; Morphine sulfate effective in decreasing pain as evidenced by patient saying when asked if she still has pain, "no." L .Long, RN

NSG 1400 Med Note		Free text; late entry: patient awoke from nap yelling. When asked if she had pain, she said, "yes." When asked if her tummy hurt, patient said "no." Asked if patient had a headache: patient said "yes." Then patient yelled "oh, oh, oh, hurry!" Doctor notified; patient medicated with Morphine sulfate 5 mg per Doctor's order. L. Long, RN

NSG 1530 Med Note		Free text, med note entry: patient asked if she was still in pain. Patient said "yes" patient asked if she had head or tummy pain and patient responded "yes," although her diminished mental condition makes her responses suspect as far as accuracy goes. L. Long, RN

		(Mistaken entry - crossed out)

(No time noted) NSG		Behavior - patient called out repeatedly, patient was alert and disoriented. Patient remained with decrease affect all shift. Intervention - patient offered medications, meals, redirection, decreased stimuli at bedtime, one-on-one care for activities of daily living. Response- patient had short term compliance with redirection, resistant to ADL cares, grabbing caregiver's hands. Compliant with crushed medications in juice. Limited vocabulary when responding verbally (continued) --------------------------------------------------------------------------------------

		(continued) or calling out. Patient was restless in bed, needing repositioning twice. Plan - explain all procedures to client, set limits for behaviors, document medication effects on behavior. R. Clark, LPN

1/03/96		(Mistaken entry - entire page crossed out)

1/04/96 0430		Med note - patient awakened - moaning, complaint of pain. Tylenol given as ordered. T. Scholl, RN

0600		Patient continues to moan - Tylenol had little effect. T. Scholl, RN Awake most of the night. Moaning, patient states "I hurt." Unable to tell pain location. Oxygen at 2 liters per nasal cannula. Color good. Asked for a drink of water and pill pill. (?) Shelton, CNA

1430		Behavior - patient has had a flat affect today. Patient has been hitting out at staff and spitting food at staff. Intervention - offered patient meals, groups, redirect. Response - patient ate 5% of breakfast and 90% of lunch. Patient needs much encouragement to participate in groups and to cooperate with staff, when they do transfers and when they give her medications. Plan - to continue to encourage patient when agitated and continue to redirect when confused. ( ? CNA)

1/4/96 2010		Patient coughing profusely with audible wet lung sounds noted after transferred to bed. No cyanosis noted, face reddened. Doctor Weitzel notified - ordered to notify respiratory therapy for treatment. Respiratory therapy notified. Suction set up at bedside if needed.

2015		Respiratory therapist arrived to unit, assessed patient. Patient with good strong cough reflex. Patient coughing up thick, mucousy, brown (from food or applesauce?) secretions. Less distressed.

2025		Patient no longer coughing, resting quietly in bed with eyes open. Respirations even and unlabored. Oxygen at 2 liters per nasal cannula.

2200		Patient turned on to left side. Resting quietly with eyes open. Respirations even and unlabored. Decreased lung sounds in bases with inspiratory scattered rales and wheezes throughout. Daughter (Karen) notified of incident. Call light within reach. D. Kley, RN

2205		Behavior- patient has been quiet this shift with somewhat glassy expression - stare. Occasionally yells out "help me!" When (continued) D. Kley, RN

1/4/96		(continued) asked what she needs, does not answer. Rocking in wheelchair after dinner, had to be asked to stop, as was posing a fall risk. Some difficulty swallowing noted at supper. Attended group; listened, however, did not interact. Took medication as ordered. Intervention - administer medication as ordered. Offered verbal redirection as needed. Provided group. Monitored behaviors. Response - patient quiet, yelling out occasionally, "help me." Attended group, did not interact, took medications as ordered. Plan - continue to administer medications as ordered. Provide groups. Monitor behaviors. Verbally redirect as indicated. Monitor lung sounds. Speech and swallow evaluation as ordered. D. Kley, RN



1/5/96 11-7		Patient slept through the night. Patient sounded gurgly early in night, suctioned once. Oxygen at 2 liters per nasal cannula. Respirations very erratic with periods of apnea. Respirations 8 to 12. Temperature 100.5 this morning. T. Scholl,, RN

0920 Med Note		Free text: Patient increasingly uncomfortable: groaning, moaning. Patient medicated with Morphine sulfate 5 mg intramuscularly. L. Long, RN

1030 Med Note		Free text: patient continued to moan and groan audibly. Patient medicated with Morphine sulfate 5 mg intramuscularly as per Doctor's order. L. Long, RN

1100		Patient silent, with eyes open, watching group activities. No answer to questions regarding her pain. L. Long, RN

1430		Behavior: patient has had a flat affect today. Interventions - offered patient meals, group, redirect. Response - patient ate 30% of breakfast and 5% of lunch but was in groups but does not track groups. Patient has very flat affect and does not respond to staff. Plan - to continue to redirect patient when she is confused. ?CNA

1/5/96 2030		Free text. Patient=s breath sounds are audibly rattling and bubbling. Patient appears to have aspirated. Patient was suctioned and some mucous removed. Patient has decreased audible rattling and bubbling, but is still present. R. Clark, LPN

3p - 11p		Problem; altered thought process. Behavior - patient is more alert today. Able to sit up at dinner. Ate 90% of puree diet with staff feeding assistance. Verbally and visually responsive to the presence of others. Continues to have much difficulty clearing secretions. Intervention - patient was evaluated by speech therapy (please see consult notes) who requests that liquids be thickened. Observe and document behavior. Administer medications as ordered and monitor effects. Provide safe environment. Response - no evidence of hallucinations or other psychotic symptoms. Required suctioning twice to assist in management of secretions. Plan - continue interventions as specified above. L. Wilson, RN

2230		Patient suctioned twice, rattling breath sounds now absent. R. Clark, LPN

1/6/96 11-7		Free text - patient appeared to sleep through the night. Respirations more frequent and even tonight. Oxygen at 2 liters/minute per nasal cannula. Patient started moaning at approximately 6 a.m. Morphine sulfate 5 mg intramuscularly given for pain, as ordered, at 6:15 a.m. Patient appears more comfortable after receiving Morphine sulfate. T. Scholl, RN



1400		Behavior - patient has not hit or kicked anyone but has called out at times and been oppositional. Patient had to be fed, patient wouldn't feed herself. Intervention - support, one-ona-one time. Medications as per Doctor. Therapeutic environment. Response - demanding and withdrawn and doesn't acknowledge staff. Plan - medications as per Doctor. Therapeutic environment. E. Cozzins, RN

1/6/96 1710		Free text - patient medicated with Tylenol grains 10 by mouth for moaning. RN (Doe) made aware. Patient settled within 30 minutes. ? Signature

2200		Behavior - patient has moaned, "oh, help me" much of shift. When asked what she needs, does not verbalize needs. When spoken to, stares blankly at speaker. Took medications as ordered. Has not struck out at staff; however, grabs hold of whomever is near. Intervention - administered medications as ordered. Provided group, monitored behavior. Response - patient has not verbalized needs. Moaned most of shift (as needed pain medication given) Stares blankly. Did not participate in group. Took medications as ordered. Coughing a lot after Depakene syrup - suctioned back of throat with Yoncher, wet lung sounds. Oxygen 2 liters per nasal cannula. Plan - continue to administer medications as ordered. Provide groups. Redirect as needed. Monitor lung sounds closely. Monitor behavior. D. Kley, RN

1/7/96 11-7

1400

Night shift free text. Patient rested quietly throughout shift. Awake several times. Suctioned once for small amount, thick, dry, oral secretions. Respirations remain labored. Oxygen continuous by nasal cannula. Color pale. L. Wilson, RN

Behavior patient has had no episodes of being combative because she has been lethargic all shift. Intervention - Dr. Dienhart notified of patient's status. Family notified. Patient had oxygen per mask. Suctions times 3 by nurse and twice by respiratory therapy. Chest x-ray taken, lab drawn. Response - patient having labored respirations with periods of apnea. Saturation level 80 to 70 pulses irregular. Patient lethargic to almost unresponsive. Plan - medications as per doctor. Close observation. E. Cozzins, RN

1/7/96 2200		Behavior - patient has been unresponsive his whole shift. Intervention - comfort measures, turned every two hours. Morphine sulfate given. Response- patient Cheyne-Stoking very cyanotic. Plan - family with patient. Patient "Do Not Resuscitate." Morphine sulfate for comfort. E. Cozzins, RN

2335		Expired. Belongings with family.

Psych Eval History & Physical Discharge Summary Chemistries CBC's CXR's

Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment

Physician's Orders Progress Notes Nursing Staff Notes Medication Administration Record

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