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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
Phone Intake COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
| 12/28/95
MD |
Psychiatric evaluation done and dictated. Diagnosis: major depressive disorder with psychotic features. Plan - Risperdol / Serzone,/ Trazodone. Medical workup. Duragesic for pain. Robert Weitzel, M.D. | |
| 12/29/95
MD |
Labs are within normal limits except chemistries - potassium quite low, sodium is also low, consistent with polydipsia, but it's not at dangerous levels. Remains dysphoric and somewhat difficult. Vital signs are stable, afebrile, blood glucose so far is in normal range. Assessment - same. Plan - continue current care. Robert Weitzel, M.D. | |
| 12/29/95
Social Service |
Patient was cognizant and alert when Social Worker I gave her the admission CQI's. Patient scored a 14 on the mini-mental status exam, and a 7 on the Geriatric Depression Scale. D. Padilla, SWI, K. Steglich, CSW | |
| 12/30/95
MD |
Urinalysis reveals urinary tract infection. Appears the Duragesic is only moderately helpful. Helping very little with transfers. Remains dysphoric, cries out frequently. Vital signs stable - blood pressure under good control. Afebrile. Assessment - major depressive disorder with psychotic features. Plan - change Lasix to every day, discontinue Dyazide per Dr. Dienhart recommendation Cipro against urinary tract infection Robert Weitzel, M.D. | |
| 12/30/95
Nursing |
Weekly advocate note: patient is new admit as of 12/28. Please see intial nursing assessment, nursing note, and treatment plan regarding goals and patient condition. L. Wilson, RN | |
| 12/31/95
MD |
Reportedly has been on Tranxene against seizure disorder. Blood glucose elevated on the last ordered Accuchex. Slept poorly. Remains dysphoric. Assessment - stable. Plan - continue current medications. Increase Trazodone at bedtime. EEG. Follow Accuchex another day. Robert Weitzel, M.D. | |
| 1/1/96
MD Sodium 135 Potassium 3.4 Glucose 88, to 317 |
Woke frequently last night, secondary to possible pain. Quite aggressive this morning. Very difficult with nurses and struck out at other patients. Has a fistula from rectum to vagina, passing feces through vagina. Trying to bite staff. Occasionally balks at taking medications. Intramuscular Ativan seems to help. Sodium has increased. Assessment - no improvement. No major polydipsia. Does seem in pain and the current Duragesic patch is certainly not sedating her. Pharmacist recommends 50 mg Duragesic. Glucose level is unstable. Plan - insulin sliding scale. Continue 50 mcg patch. Increase Trazodone. Robert Weitzel, M.D. | |
| 1/02/96
MD |
Slept last night. Gynecologist will probably see her today. Glucose fluctuating. Vital signs stable, afebrile. Assessment - improved with increased Trazodone. Plan - continue current care. Robert Weitzel, M.D. | |
| 1/03/96
MD |
EEG read as possible seizure: diffuse slowing, possibly metabolic versus cerebrovascular accident. Clinically, she shows evidence of absence and partial complex seizures. Continues to call out a lot, behavior is a problem. Quite febrile today, other vital signs stable. Continues to get insulin. Assessment - Diabetes Mellitus. Seizure disorder probable. Major depressive disorder with psychotic features. Plan - Add Depakene, change diet, oxygen by nasal cannula, check urinalysis tomorrow (now off Cipro). Robert Weitzel, M.D. | |
| 1/4/96
MD |
Glucose is slightly elevated, generally mostly at 11 a.m. Is crying out quite a bit, apparently in quite a bit of pain. No longer febrile. She answers "yes" to questions as to if she's in pain; when asked "where ?" repeats "all", when asked if this means "all over" replies "yes." Assessment - breakthrough pain. Plan - Morphine sulfate prn (as needed), increase Duragesic. Robert Weitzel, M.D. | |
| 1/4/96
OT |
Occupational Therapy note - Seating cushing has been researched and OT will discuss funding source and order of cushion with team tomorrow at team meeting. S. Nelson, (OTA?) | |
| 1/4/96
Individual Therapy |
Individual session - talked to patient one-on-one. She was moaning throughout the session and could not be engaged in conversation. Staff reports that patient does talk, and frequently becomes agitated. S. Bennion, LCSW | |
| 1/4/96
Social Service |
Social Work weekly progress summary. Patient has been involved in group and adjunctive therapies this week. According to group facilitators, patient's participation has been minimal. Individual therapy has been attempted but patient was unable or unwilling to engage. Continue with master treatment plan. S. Bennion, LCSW | |
| 1/5/96
MD |
Continues to cry out in pain. Swallowing poorly - I was informed she may be aspirating. Has had fever, intermittently; this morning 100.5 now 99.9. To have swallow evaluation this evening. Assessment - no improvement. Plan - probably will hold on surgery. Chest x-ray and CBC. Morphine sulfate against pain. Robert Weitzel, M.D. | |
| 1/5/96
OT |
Occupational therapist met with team and social worker to make recommendation for seating adaptation. Social worker will contact patient's family to arrange purchase. Nelson OTR | |
| 1/5/96
OT |
Occupational therapy weekly summary: Patient unable to attend to a task or follow a simple one-step command at this time. Patient is unable to communicate her wants or needs with verbal cues and minimal assistance. J.V ? COTA/L | |
| 1/5/96
Family Therapy |
Phone conversation with patient's daughter Karen. We discussed patient's condition and possible discharge plans. Her family is checking out other long-term care facilities before making a placement decision. I will talk to the family again next week about patient's progress. S. Bennion, LCSW | |
| 1/?/96
Dietary |
Patient receiving puree with thick
liquids secondary to recommendation from speech therapist. Patient oral
intake varies 5 to 100%, generally 60-80%. Good intake secondary to staff
has to feed her because she spits or throws her food. Diet order: decreased
fiber, decreased residue, 1800 ADA diet with thick liquids puree. Sending
snacks twice a day. Weight 148 lbs. Accuchex: 127. 12/28/95 - Albumin 2.9
(moderate depletion ) Total protein 5.6 decreased BUN 35 - 31.
Toni Anderson, RD |
|
| 1/6/96
MD |
Remains much less labile and aggressive, but the tradeoff is some lethargy. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. Robert Weitzel, M.D. | |
| 1/7/96
MD |
Has become quite ill today: febrile, low blood pressure, had extremely low oxygen saturation, sodium highly elevated, unresponsive; thrashing, with apparent pain and/or anxiety. Abdomen is distended. White blood cell count elevated, may have had a seizure earlier and aspirated. I have spoken with her two daughters and they do not want extraordinary measures taken, but would rather have comfort care given. Assessment - probable aspiration pneumonia, quite demented, hypotension, possible sepsis, volume depletion. Plan - will respect family's wishes; provide comfort care but no extraordinary care. Robert Weitzel, M.D. | |
| 1/7/96
Nursing Free text note |
Free text note. Several immediate family members present with patient at 11 p.m. Patient remains unresponsive. Cheyne-Stokes respirations. Nursing supervisor present on the unit. At 11:40 pm patient is without vital signs. Dr. Weitzel has been notified of patient=s death and will request emergency room physician Dr. B. Neilson MD to pronounce patient. Midnight: Dr .B. Neilson, MD in to pronounce patient=s death. Larkin Mortuary has been notified by Kathy Dean, RN, Nursing supervisor. Emotional support provided to all family members. All are tearful but accepting of Mary=s death. Family members have retrieved all patient belongs from her room. Larkin Mortuary arrived at 0130. Laurie E. Wilson, RN, MSW | |
| 1/8/96
MD |
As noted, patient died shortly
before midnight. Body released to mortuary. Discharge summary dictated.
Robert Weitzel, M.D.
|
|
| 1/8/96
OT |
Occupational therapy discharge note. Patient died around midnight. J.V...?COTA/L | |
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
