1400

COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

Ennis Alldredge Nursing Staff Notes

1400		83 year old white male admitted and oriented to the unit. Patient accompanied by his wife of 7 years. Patient is very combative and agitated. Patient not oriented to time, place, person or situation. Patient is not able to walk. Patient keeps taking off his clothes. Patient refuses to eat, throws his hamburger across the room. Has not verbalized anything understandable, but cries very loud frequently. Is very strong and grabs at staff hurting staff. E. Cozzins, RN

1415
Med Note

Free text: Patient agitated, trying to hit, squeeze hands of caregivers, trying to bite, yelling incomprehensively. Patient medicated with Haldol 10 mg intramuscularly and Ativan 1 mg intramuscularly, results pending. L. Long, RN

1/10/96		Behavior: patient has been lethargic and unresponsive to staff. Patient has been in bed with restraint on because of agitation. Patient has been checked every 2 hours and restraint has been released. Intervention - offered patient water, range of motion. Behavior - patient refused water and was resistant with range of motion and combative at times with staff. Plan - follow care plan, redirect patient when aggressive and agitated. T. Sprague, CNA

1400		(crossed out - mistaken entry - E. Cozzins, RN)

1/10/96 1200 NSG 1/10/96 1400 NSG		Day shift notes, continued: Late entry; patient's restraint released for circulation check, range of motion, peri care, offer of food and beverages. Patient's restraint reapplied as patient is trying to get up without assist, plus is assaultive towards staff: hitting, trying to kick, bite. Late entry; free text: patient's restraint released for circulation check, range of motion, peri care, offer of water. Patient extremely combative; kicking, hitting, squeezing staff hands and not letting go, trying to get out of bed without assist. Posey restraint reapplied; conditions for release explained to patient but patient is unresponsive verbally. L. Long, RN

1/10/96 1600 NSG		Free text: At 1600 staff released restraint on patient to check circulation and do range of motion and also offered water and bathroom privileges which patient refused. T. Sprague, CNA

1/10/96 1800 NSG		Free text: at 1800 staff released restraint on patient to offer water and bathroom privileges. Patient refused the offer. Circulation was checked and range of motion of limbs was done. Reapplied restraint. T. Sprague, CNA

1/10/96 2000 NSG		Free text: at 2000 staff released restraint on patient. Patient was still combative with staff. Circulation was checked. Range of motion was done. Offered water and bathroom privileges. T. Sprague, CNA

1/10/96 2200 NSG		Free text: at 2200 staff released restraint on patient. Patient was offered water and bathroom privileges. Range of motion was done and circulation checked. Reapplied restraint. T. Sprague, CNA







1/11/96 2400		Patient restless - Poseyed - Posey undone - patient repositioned. See restraint addendum record for additional information. T. Scholl, RN

0200		Patient continues restless removing bedding. Posey undone - range of motion and patient repositioned and re-Poseyed due to agitation. T. Scholl, RN

0400		Patient restless but sleeping. Diaper remains dry. Posey off, patient repositioned - re-Poseyed. Both side rails up. Bed check monitor in place (T. Scholl, RN).

0600		Urinalysis obtained by straight catheterization. Patient very agitated, crying loudly. Posey removed - range of motion - repositioned and re-Poseyed. See restraint addendum for additional information. . T. Scholl, RN Patient tolerated catheterization procedure well. T. Scholl, RN

0800		Patient was offered liquid and breakfast; patient just spit everything out. Pulled up and straightened in chair. A. Kennedy, CNA

2:00 p.m.		Behavior - patient has been agitated, hitting, spitting. Intervention - offer group and meals (continue) (A. Kennedy, CNA)

1/11/96 2:00 p.m.		(continued) Response - Attended groups but slept. When offered meals kept spitting it out. Plan - continue to offer meals and groups. A. Kennedy, CNA

1/11/96 0800		Patient was released from restraint to be washed and sat up in chair for breakfast and re-Poseyed. A. Kennedy, CNA

1000		Patient was pulled up and repositioned in chair. A drink was offered but patient just spit it out. A. Kennedy, CNA

1200		Patient checked for changing, still remains dry. Offered lunch and drink but becoming agitated and spitting. A. Kennedy, CNA

1400		Patient released from Posey to transfer to bed. Patient was kept un-Poseyed while gown was being changed and while being positioned in bed. Patient was re-Poseyed in bed. A. Kennedy, CNA

1500		Patient sitting quietly in chair in hall with Posey restraint in place. Continuously leaning forward in chair as though to arise. D. Kley, RN

1700		Patient in chair with Posey in place. Dinner tray served. Patient assisted with eating - pushes Certified Nurses Assistant=s hands away. Has been released every 2 hours for toileting, exercise, repositioning. D. Kley, RN

1800		Refused Nystatin swish and swallow and glycerin swipes - hitting, slapping, closing mouth tightly. D. Kley, RN

1900		Patient falling asleep in chair. Taken to bed, (continued) (D. Kley, RN)

1/11/96 1900		(continued) Bedtime cares done. Posey restraint in place. D. Kley, RN

2000		Patient asleep - would not awaken to take bedtime medications. D. Kley, RN

2100		Patient awake. Took bedtime medication, except Docusate Sodium, refused, spit out. Gave Sustacal as blood sugar equals 67 - will monitor. Posey in place. Has been every 2 hours for toilet, exercise, repositioning. D. Kley, RN

2200		Behavior - patient has been calm and quiet this shift except when someone within reach, then patient grabs, hits at staff. Ate none of dinner. Patient combative during cares. Posey has been in place this shift without adverse affects noted. Intervention - toileted, exercised, repositioned every 2 hours this shift. Administered medications as ordered, provided group, one-on-one time. Provide quiet, low stimuli, structured environment. Verbal redirection as needed. Response- patient combative during cares. Refused supper. No adverse reaction effects noted secondary to Posey restraint. Disoriented. No insight as to situation. Does not respond to verbal redirection. Hitting, grabbing, spitting when staff attempt to assist, perform cares. Plan - (continued) (D. Kley, RN)

1/11/96 2200		(continued) to administer medications as ordered. Provide group. Provide quiet, safe, low stimuli, structured environment. Redirect as needed. D. Kley, RN

2220		Patient awake, agitated, - trying to get out of bed, striking out at caregivers, grabbing. Attempted to give Aas needed@ Trazadone as ordered, patient refused, spitting. D. Kley, RN Will see if patient calms down on own, with lights dimmed. D. Kley, RN

2230		Patient remains agitated, restless, hitting out at caregivers. Gave Ativan 1 mg intramuscularly as ordered. Will monitor effectiveness. D. Kley, RN

2300		Patient awake, but has calmed down - no longer agitated. Resting quietly, respirations even and unlabored. Posey restraint in place without adverse affects noted. D. Kley, RN

(1/11/96) 2345		Patient remains Poseyed. Patient had large bowel movement - has smeared feces all over including face, bed rails, etc. Patient cleaned up in recliner - bedding changed, back to bed and Posey resecured. T. Scholl, RN

1/12/96 0100		Patient resting quietly - sleep study in progress. T. Scholl, RN

0200		Patient's Posey removed - range of motion - patient repositioned - Posey resecured. Both side rails up. Bed check monitor in place. See restraint addendum record for additional information. T. Scholl, RN

0400		Patient has been agitated and restless. Removing diaper - removed finger monitor - unable to replace - respiratory therapy called. Posey removed - range of motion - repositioned. Posey secured. T. Scholl, RN

0415		Ativan 1 mg intramuscularly given for agitation. Respiratory therapy in, finger monitor replaced. T. Scholl, RN

0600		Patient continues to be mildly agitated - refusing to leave on finger monitor or to keep covered up. Posey removed. Range of motion. Patient repositioned. (continued) (T. Scholl, RN)

1/12/96 (11p - 7a) 0600		(continued) and Posey back on. See restraint addendum for additional information. Both side rails up. T. Scholl, RN

0700		Day shift notes continued on separate sheet, other side. L. Long, RN

1600		Free text: Patient released from Posey restraint for circulation check range of motion, offer of water, peri care. Patient agitated when cares done; pinching, hitting, not responding to redirection. Restraint reapplied for patient=s safety as patient tries to get up without assist. L. Long, RN



1/12/96 0800 NSG		(Day shift notes continued). Free text: Posey restraint released for range of motion, circulation check, peri care, offer of food and water. Patient trying to hit and spit at staff, and trying to get up without assist. Redirection attempted but patient unresponsive to verbal cues. Posey belt reapplied for patient safety. Patient helped to day room for breakfast in chair with Posey on. L. Long, RN

0820 NSG Med Note		Free text: patient refused all oral medication by spitting out anything put in his mouth, trying to slap away nurses hands, muttering angrily. Patient medicated with Haldol 5 mg intramuscularly. L. Long, RN

1000 NSG Med Note		Free text: Patient continues to refuse all oral offerings, and continues to try to get up without assist. Posey restraint released for peri care, circulation check, range of motion, offer water and food. Restraint reapplied for patient safety. Patient continues to spit out all oral materials; i.e. food, medications, water. L. Long, RN

1200		Free text: Patient released from restraint for circulation check. Range of motion, peri care, offer of water and food. Patient continues to be agitated, trying to get up without assist and spitting, hitting at staff. Restraint reapplied for patient safety. L. Long, RN

1245 Med Note		Free text: patient medicated with Ativan 2 mg intramuscularly for extreme agitation prior to MRI scheduled for 1 p.m. L. Long, RN

1330 Med Note		Free text: MRI personnel report patient remains agitated. Patient medicated with Ativan 1 mg intramuscular and Haldol 5 mg intramuscularly per Doctor=s order. Results pending on medication. L. Long, RN

1410 Med Note		Free text: patient returned from MRI room (continued) L. Long, RN - over

1/12/96 1410		(continued) by MRI personnel who reported patient remains too agitated to conduct MRI. Patients restraint released for range of motion, peri care, circulation check, offer of water and food and juice. Patient refusing everything by mouth, clenching teeth, trying to hit staff, trying to get up without assist. Posey reapplied for patient=s safety. L. Long, RN

1500		Behavior - patient has been agitated or lethargic alternately all shift; trying to bite, hit, or spit at staff during all interventions. Patient mumbled unintelligibly when care given or medications or food offered; trying to slap away hands of staff. Intervention - offered one-to-one, medications as ordered, meals, groups. Response - patient refused anything by mouth and was unresponsive to all interventions except to be aggressive towards staff. Plan - therapeutic, safe environment; Posey restraint for patient safety at all times. L. Long, RN

3p - 11p 1700		Behavior - patient is somnolent, sitting in recliner chair. No response to group activity taking place around him. Remains in Posey belt for safety. (L. Wilson, RN)

1800		Intervention - MRI: Doctor Klinger called to report evidence of possible new infarct left occipital lobe. Patient remains restless and minimally responsive except to discomfort. Doctor Weitzel has been notified of MRI results. In view of patient=s diabetes and possible dehydration (continued) (L. Wilson, RN)

1/12/96 1800		(continued ) 3-11 note: Doctor Weitzel has ordered IV line of D5 2 NS at 100 cc per hour. Doctor Weitzel plans to talk with family in morning regarding MRI results and plan of care. Patient released hourly from restraint.

2000		IV stick very difficult. This nurse attempted once in left wrist. Patient rotated away as needle was in the vein. Pressure applied to left wrist site. ICU nurse called to assist with future needle stick while Geropsych staff restrained the patient. Patient is not verbally responsive. Shows random, strong limb movements in response to painful stimuli. ICU nurse attempted 3 needle sticks before successful stick in left forearm. Patient's hands have been loosely restrained in order to prevent disruption of IV site. Patient remains verbally unresponsive with strong random limb movements. IV infusing D5 2 NS at 100 cc per hour, 22 gauge needle.

2200 Med Note		Response - patient is calm in 3-point restraint. All oral medications have been held this evening due to patient's inability to swallow. Intramuscular medication not utilized due to patient's extreme sedation and altered mental status. Plan - continue to provide for patient's safety. Monitor medical status. (Accuchex 1600: 97. 2000:87). Provide IV fluids as ordered. Range of joint motion, turn, provide for personal care every 2 hours. Continue 15 minute checks for safety. L. Wilson, RN

1/13/96 11p - 7a
2400

0200

0400

Night shift every 2 hour charting.
Patient is wakeful and restless in bed. Eyes closed. Moving all limbs while in Posey belt and wrist restraint. At risk to fall out of bed. At risk to pull out IV in left forearm (D5 2 NS at 100 cc. per hour presently infusing well and intact). IV is medically necessary due to dehydration and patient with diabetes. Patient repositioned, restraint released then reapplied. L. Wilson, RN
Addendum - patients diaper changed for small amount urinary incontinence. L. Wilson, RN
(Wrong patient - note crossed out).
Patient is somnolent. Continues to have random limb movement but is not directly responsive to staff interventions such as diaper change and range of joint motion. Posey and wrist restraint removed briefly and reapplied to prevent injury to patient. L. Wilson, RN
Patient incontinent large amount of urine in bed. Patient was repositioned and perianal care was provided by two staff members. Patient is more wakeful and is combative, pinching, grabbing and striking out. Ripping off incontinence brief as soon as it is applied. Posey belt and wrist restraints reapplied for patient and staff safety. L. Wilson, RN

1/13/96

0600 Bottle #2 D5 2 NS hung, infusing well into intact IV site at left forearm. Rate 100 cc per hour. Patient is more alert and restless. Posey belt and wrist restraint intact. Not removed at this time due to patient=s high level of agitation and risk of assault. L. Wilson.

1/13/96 11p - 7a		Please see every 2 hour charting on attached sheet for 11 to 7 shift. L. Wilson, RN
0800		Patient unresponsive. Family with patient. Posey and restraints taken off. IV discontinued. Comfort measures given. E. Cozzins, RN Doctor Weitzel talked with family. Doctor Dienhart notified of patient=s declining condition. E.Cozzins, RN

1500		Behavior - patient has been unresponsive the whole shift. Intervention - turned every two hours. Comfort measures and oral care. Response- respirations irregular with periods of apnea, color pale. Plan - comfort measures. Family support. E. Cozzins, RN

1/13/96 (1500 –2300)		Behavior - patient unresponsive this shift during cares and intramuscular medication administration; no response to ministrations of family members present at bedside. Intervention - offered comfort care: every 15 minute checks, peri and mouth care, turning every two hours, medications as ordered. Response - patient unresponsive, with long periods of apnea, every 1 to 2 minutes. No discomfort noted during cares. Plan - medications as ordered, comfort care. L. Long, RN



1/14/96 11p-7a 0600 Med Note		Night shift free text note. Patient's level of awareness has been progressively "sinking" over the shift. All family members have been present intermittently. Wife has remained at his side throughout shift. 0500 dose of Morphine sulfate 10 mg and Ativan 0.5 mg were given at 0430 due to patient grimacing and labored breathing indicating his level of distress. Cheyne-Stokes respirations continue with periods of apnea lasting up to 30 seconds. Patient was given nasotracheal suctioning by respiratory therapy once at 0400 for comfort. Continues to have deep chest "rattle" as of 0600. 0600 Doctor Weitzel gave telephone order for Morphine sulfate 10 mg intramuscularly. Given in left gluteus. No response from patient to that needle stick. Family remains with patient, comforting him and talking with him, asking him to "let go."

0735		Patient with deep labored respirations. Patient turned: moaning turning procedure. (continued) B. Hardy, RN

1/14/96 0735		(continued) Patient has thick mucous drainage from mouth. Oral care given. Lungs with rales throughout. Cyanotic extremities. Family members at bedside. B. Hardy, RN

0800		Patient given 10 mg Morphine sulfate intramuscularly due to continued moaning. Patient respirations remain labored. Patient with eyes open, staring. Family remains at bedside. (Vital signs - Temperature - 101.8. Pulse 84. Respirations 16. Blood Pressure 110/72).B. Hardy, RN

0920		Patient to be given now order of 10 mg Morphine sulfate intramuscularly and Ativan 0.5 mg. Patient with decreased functioning. Apnea 60 seconds. Heart rate tachycardic and thready. Medication held. No peripheral pulses in arms and legs. Cyanotic extremities. Family at bedside, aware of decline in condition. Wife awakened from sleep to be with patient. B. Hardy, RN

0930		Patient condition declining. Respirations every 80 seconds with gasping noted. Heart rate tachycardic and weak, apically.

0936		Patient has had no heart rate, no respirations, no blood pressure x 5 minutes. Doctor Weitzel, family and nurse supervisor informed. (continued) B. Hardy, RN

1/14/96 0940		(continued) Family at bedside, tearful, supportive of one another. Mortuary in Delta: Nichol's Mortuary notified. B. Hardy, RN

0955		Family requested use of typewriter to write obituary. Family members continue to arrive, supportive of each other. Wife requested to gather personal belongings. Staff assisted with containers and release of property form. B. Hardy, RN

1410		Mortuary from Delta, Utah arrived for patient's body. Family gave thanks to staff and departed. B. Hardy, RN

Psych Eval History & Physical Discharge Summary

Living Will / Medical Treatment Plan

Physician's Orders Progress Notes Nursing Staff Notes

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