Ennis Alldredge

(continued) Assessment - Cerebral vascular accident,etc. Plan - discontinue IV, decrease insulin, discontinue oral medications. Morphine sulfate 10 mg every 3 hours intramuscularly, Ativan 0.5 mg every 3 hours intramuscularly, Haldol as needed. Robert Weitzel, M.D.

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
1. Discontinue IV
2. Morphine sulfate 10 mg intramuscularly every 3 hr
3. Ativan 0.5 mg intramuscularly every 3 hr
4. Discontinue all oral medications
5. Discontinue Haldol prn as written
6. Haldol 10 mg intramuscularly every 4 hrs as needed for severe agitation
Thanks, Robert Weitzel, M.D.

1/13/96
1. Lente insulin decreased to 10 units subcutaneously every morning and 2 units subcutaneously every afternoon
2. Discontinue Accuchex
Signed Robert Weitzel, M.D.
1/13/96 E. Cuzzins, RN 0800

Chronochart

Ennis Alldredge PHOTO>>

Brief History and Hospital Course

This 82 year old married white male had had fairly rapid decline in mental status thought to be due to multi-infarct dementia, rule/out Alzheimer’s. He had a twenty year history of IDDM, long history of hypertension with CAD, S/P CABG 10 years prior, renal insufficiency, and end stage mycoses fungoides previously treated with total body irradiation. He had been at Sunshine Terrace Nursing Center, but had recently become highly agitated and aggressive; hitting, scratching, kicking; he threw a wheelchair and fractured the hip of another (female) resident there. Ativan 3 mg. twice did little to calm him, and the nursing home was unable to contain him; he was transferred to Davis Hospital.

On admission Mr. Alldredge proved extremely difficult as he was still quite strong for his age, and frequently hurt the nurses. He was continued on insulin, Pepcid, L-thyroxine, Bumex, Micro-K, Hytrin, Oxybutynin, and ASA, and started on Risperdol 1mg. tid, Buspar 10 mg. tid and trazodone 100 mg.qhs. Because he frequently refused oral medication, and was extremely combative, a danger to himself and others, he received Haldol 10 mg. and Ativan 1 mg. IM as now and prn orders; he remained intermittently quite agitated until late on the fourth hospital day.

MRI on the third day of admission revealed what appeared to radiology to be a new left occipital infarct. He was also pyuric and dehydrated at this point. An IV was started for hydration, as the patient would not swallow fluids or medication.

On the fourth hospital day a family conference was held; the wife was called. The CVA was described and the family told that an occipital stroke might cause blindness. The situation with the patient’s refusal to swallow and diabetes necessitating IV fluid was discussed. In view of the patient’s rather clear and compelling Living Will of July, 1993, (which precluded IV) his family was offered withdrawal of interventions and comfort care, versus transfer to ICU. His family elected to withdraw care, and the IV and all previous medications were discontinued; instead the patient received regular doses of morphine 10 mg. IM q3hrs (due to patient "grimacing" and "moaning") and Ativan 0.5 mg. q3hrs until he died the next day.

LIVING WILL

Ennis Alldredge

I, ENNIS Alldredge, a resident of the Town of Oak City, County of Millard, State of Utah, being of sound and disposing mind, memory and understanding, do hereby willfully and voluntarily make, publish and declare this to be my LIVING WILL, making known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

1. This instrument is directed to my family, my physician(s), my attorney, my clergyman, any medical facility in whose care I happen to be, and to any individual who may become responsible for my health, welfare or affairs.

2. Death is as much a reality as birth, growth, maturity and old age. It is the one certainty of life. Let this statement stand as an expression of my wishes now that I am still of sound mind, for the time when I may no longer take part in decisions for my own future.

3. If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures and "heroic measures" would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally. I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain. I therefore ask that medication be mercifully administered to me and that any medical procedures be performed on me which are deemed necessary to provide me with comfort, care or to alleviate pain.

4. In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.

5. In the event that I am diagnosed as comatose, incompetent, or otherwise mentally or physically incapable of communication, I appoint Bradley Alldredge, and Myrna A. Gromwald (respectively and individually in that order) to make binding decisions concerning my medical treatment.

6. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. I hope you, who care for me, will feel morally bound to follow its mandate. I recognize that this appears to place a heavy responsibility upon you, but it is with the intention of relieving you of such responsibility and of placing it upon myself, in accordance with my strong convictions, that this statement is made.

IN WITNESS WHEREOF, I have hereunto subscribed my name at Oak City, Utah this 30^th day of July, 1993, in the presence of the subscribing witnesses whom I have requested to become attesting witnesses hereto.

(Signed) Ennis Alldredge

The declarant, ENNIS Alldredge is known to me and I believe him to be of sound mind.

(Signed) Betty Jeffrey Delta, Utah

Witness Address

(Signed) Nancy Oppenheim Delta, Utah

Witness Address

STATE OF UTAH )

: ss:

COUNTY OF MILLARD )

Subscribed, sworn to and acknowledge before me by ENNIS Alldredge, the

declarant, and subscribed and sworn to before me by

(Signed) Nancy Oppenheimer and (Signed) Betty Jeffery ,

witnesses, this 30^th day of July, A.D. 1993.

(Signed) Claudia Terrell

[Notary Public Seal] Notary Public

Copies of this instrument have been given to:

Receipt and acknowledged (Name, Address & date):

(Signed) Bradley Alldredge

(Signed) Myrna Gromwald

Ennis Alldredge Phone Intake Data

Ennis Alldredge Nursing Admission Assessment Page 1

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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

	1/10/96 MD		Patient seen and examined. Psychiatric evaluation dictated. Diagnosis: Psychosis, not otherwise specified. Plan: increase Risperdol, continue Buspar, use Haldol intramuscularly if patient unwilling to take Risperdol. Possible Depakote. Robert Weitzel, M.D.

DAVIS HOSPITAL & MEDICAL CENTER

PSYCHIATRIC EVALUATION

PATIENT: Alldredge, Ennis

Robert A. Weitzel, M.D.

1/10/96

IDENTIFYING INFORMATION

This is a 82-year-old, married white male who has been living at the Sunshine Terrace Nursing home.

CHIEF COMPLAINT

"Who are you."

HISTORY

The patient has recently become very aggressive and combative, hitting and kicking people. He had to be restrained in a geri-chair. He has had dementia diagnosis for some time, but only recently has become a risk to himself and other residents and staff. He does exhibit sun-downing. Ativan up to 3 mg IM times 2 has been tried, but has often not been helpful. He also has been prescribed Risperdal ½ mg and a 1 mg b.i.d., but this has not been helpful. He has been having negative incidents daily. I spoke with Dr. Cunningham in Logan yesterday and approved admission. I was not informed that he is non-ambulatory before the admission.

PAST PSYCHIATRIC HISTORY

Negative.

PAST MEDICAL HISTORY

He had a hernia repair in 1990. He apparently has had a CABG. He has been a diabetic since the 1970s. He is on fairly high doses of insulin, i.e. lente 20 units q a.m. and 5 units q p.m. He is on Pepcid 20 mg q day. He was on Risperdal and that has been increased here. He had been on Benadryl for sleep and this has been changed to Trazodone here. He has been on Bumex 1 mg q a.m., aspirin 325 mg b.i.d., Oxybutynin 5 mg po b.i.d., Micro-K 10 mEq q day, Hytrin 5 mg q hs, DSS 100 mg po b.i.d., and Buspar 10 mg po t.i.d. Basically his latest labs which were faxed to us appear to show no major abnormalities.

continued…..

PSYCHIATRIC EVALUATION

ALLDREDGE, Ennis

continued…pg2

Robert A. Weitzel, M.D.

SOCIAL HISTORY

The patient is married, but he is in a nursing home. His wife does not live there, of course.

FAMILY HISTORY

Negative for psychiatric disorder.

SUBSTANCE USE: Alcohol and drug history are negative.

PATIENT STRENGTHS

None that I am aware of.

PATIENT LIMITATIONS

Dementia, combative behavior, multiple medical illnesses.

MENTAL STATUS EXAMINATION

In general, he is an elderly appearing white male who is agitated and difficult to control. Speech – he has some slurring. Mood is quite dysphoric. Affect – congruent and labile. Thought process – quite loose and exhibits blocking. Thought content – difficult to ascertain secondary to patient being uncooperative. Perceptions – hearing and vision seem adequate. Cognition – IQ seems grossly impaired. Calculations not tested. Memory is very poor, obviously, but he will not cooperate with testing. Abstractions – not tested. Fund of knowledge – not tested. Insight – poor. Judgement – poor.

DIAGNOSIS

Axis I: Psychosis NOS.

Axis II: Defer.

Axis III: Dementia, history of dyspepsia, possible peptic ulcer disease treated with Pepcid. Hypertension treated with Bumetanide and Hytrin. Hyperthyroid treated with L-thyroxin. Constipation treated with Docusate sodium.

Axis IV: 4.

Axis V: 22.

continued….

PSYCHIATRIC EVALUATION

ALLDREDGE, Ennis

continued…pg3

Robert A. Weitzel, M.D.

DISCUSSION & RECOMMENDATIONS

We will quickly control his psychotic behavior with some IM Haldol and Ativan. He has currently received these and is doing well. I would like to have him on a higher dose of Risperdal. I will continue the Buspar. He will probably be started on Depakene as needed and he will have prn Ativan and Haldol.

ESTIMATED LENGTH OF HOSPITALIZATION

2 to 3 weeks.

DISCHARGE CRITERIA

No combativeness.

DISCHARGE PLAN

Back to Sunshine Terrace.

(Signed) Robert A. Weitzel, M.D.

RAW/kl

D: 1/10/96 16:25

T: 1/10/96 16:39

Job # 5699

1/10/96
Admit to Geropsychiatric Unit.
Allergies: No known allergies.
Condition: Poor
Preliminary Diagnosis: Psychosis not otherwise specified.
Activity: Bed rest, wheelchair.
Diet: 2000 calorie American Diabetic Association, no added salt, finger foods.
Labs: CBC, Chem 20, RPR, T7, TSH, Urinalysis with culture and sensitivity if indicated.
EKG
AIMES test
Chest x-ray
Occupational therapy evaluation and treatment
Vital signs: twice a day
Special precautions: check each 15 minutes for first 24 hours
Medications:
Tylenol 1-2 by mouth every 4 hours as needed for pain.
Mylanta 30 cc by mouth every 4 hours as needed for dyspepsia.
Milk of Magnesia 30 cc by mouth every bedtime as needed for constipation.
Lente insulin 20 units subcutaneously every morning Lente insulin 5 units subcutaneously every evening
Accuchex before meals and at bedtime
Risperdol 1 mg by mouth every morning, 5 p.m. and bedtime.
Pepcid 20 mg by mouth every day
L-thyroxine 0.1 mg by mouth every morning Trazodone 100 mg by mouth every bedtime, may repeat once by mouth as needed for insomnia.
Bumetadine 1 mg by mouth every morning.
Enteric coated aspirin 325 mg 1 by mouth twice every day
Oxybutinin 5 mg by mouth twice a day
Micro K (potassium) 10 meq one by mouth every day
Hytrin 5 mg by mouth every bedtime
Docusate sodium 100 mg by mouth twice a day
Buspar 10 mg by mouth 3 times a day
Do Not Resuscitate
Telephone Order - Dr. Weitzel/L. Long, RN
Signed: Robert Weitzel, M.D.
Noted, L. Long, RN 1/10/96 1300

I CERTIFY THAT THIS PATIENTNEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED: Robert Weitzel, M.D.
DATE: 1/10/96

1/10/96
1. Ativan 1 mg, and Haldol 10mg intramuscularly now.
2. Ativan 1 mg to 2 mg intramuscularly every 4 hours as needed for severe agitation.
3. Haldol 5 mg intramuscularly every morning, 5 pm and bedtime to be given Aas needed@ - if patient refuses Risperdol.
Thanks, Robert Weitzel, M.D.

1/10/96
Physical Therapy consult regarding ambulation.
Robert Weitzel, M.D.
Noted: L. Long, RN 1/10/96 1430

1/10/96 9 p.m. Medical consult note:
(asked to see by Dr. Weitzel)
Impression: Severe dementia
Agitation
History of hypertension
Coronary artery disease, status post coronary artery bypass graft 1982
Diabetes
Renal insufficiency
History of gastroesophageal reflux disease
History of mycoses fungoides -unknown stage
History total body irradiation (unreadable word)
History hypothyroidism
Urinary incontinence and
decreased rectal -anal sphincter tone
Oral thrush probable
Recommend:
1. Agree screening labs
2. Rule out urinary tract infection
3. Aspiration precautions (unknown word)
Discussion:
Demented 82 year old male admitted for combativeness and agitation.
Currently lethargic-aroused only to painful stimuli following Ativan and Haldol injection for combativeness.
Exam:
Pupils equal reactive to light, tympanic membrane within normal limits. Gag poor, mucosa red - probable oral thrush. Lungs: decreased breath sounds with wheezes. Heart: regular rhythm (indecipherable) Rectal and sphincter tone (cut off of page). Other than pending labs, chest x-ray, EKG, see no major changes in other medications. Unknown prior evaluation of dementia (cut off of page) .
Note dictated

D. Dienhart, M.D.

1/10/96 9 p.m.
Glycerin swish and swallow mouth four times a day Nystatin swab mouth 5 times a day for 7 days
Straight catheter urinalysis and culture and sensitivity if indicated.
Hemocult stool
Oxygen saturation (indecipherable) during periodic breathing
Head of bed elevated 20 degrees all times as feasible.
Signed D. Dienhart, M.D.
1/10/96 Noted B. Hardy, RN 2210

Ennis Alldredge Chest X-Ray

Ennis Alldredge EKG 1

Ennis Alldredge EKG 2

Ennis Alldredge Chemistries

Ennis Alldredge CBC

24 hour check 1/11/96 0130 T. Scholes, RN

Ennis Alldredge UA

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: Alldredge, ENNIS RM 307-01

DATE OF CONSULTATION: 1/10/96

ATTENDING PHYSICIAN: ROBERT WEITZEL, M.D.

CONSULTING PHYSICIAN: DAVID G. DIENHART, M.D.

REASON FOR CONSULTATION

Admission to the Geropsychiatric Unit, evaluation of medical problems.

HISTORY

Mr. Alldredge is a 83-year-old Caucasian male with a history of severe dementia admitted now to the Geropsychiatric Unit for increased agitation and combativeness, in transfer from the Sunshine Terrace Nursing Center. It is felt that he is an increase risk to other residents. His combativeness includes biting and kicking.

His medical history is remarkable for dementia. Medical note from Dr. Cunningham (4/17/95) which states the patient has clear loss of recent memory. He was unable to state the president of the United States. When he was asked at that time the similarities between a bowling ball and an orange, he stated "you could get juice out of a bowling ball." As mentioned he was felt to have senile dementia, Alzheimer’s type. In August of 1995 the patient was seen and voiced no complaints. It is noted in the examination that he was alert, lucid and responded appropriately to questions. His examination was unremarkable. On August 31^st, 1995, it was noted that he was disoriented and did not know the time of year. He was unable to perform simple mathematical calculations. He was said to be sometimes confused. On October 12^th, 1995, it is stated that his communication skills were disruptive and incoherent at times. On 11/16/95 it was noted and felt that he had an expressive aphasia, and seemed to understand spoken sentences to him. On 1/4/96 he was completely disoriented however awake and alert. He was unable to talk in a lucid manner. His communication was without significant meaning.

C O N T I N U E D . . .

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 2 . . .

Recent medications at Sunshine Terrace, Lente insulin injection 20 units subcutaneous q a.m., Lente insulin 5 units subcutaneous q. p.m., Risperdal .5mg b.i.d. (stopped 1/8/96), Pepcid 20mg daily, L-Thyroxin .1mg q. a.m., Diphenhydramine 25mg q. h.s., ___________ 1mg q. a.m., enteric coated aspirin one tablet p.o./b.i.d., Oxybutynin 5mg one p.o./b.i.d. Micro-K 10mEq daily, Cimetidine 800mg one p.o./q.j.s. (stopped 1/4/96), Hytrin 5mg one p.o./q.h.s., Restoril 15mg one p.o./q.h.s., BSS 100mg one p.o./b.i.d., Mellaril 25mg one tablet p.o./t.i.d. (stopped 12/28/95), Mellaril 50 mg t.i.d. from 18/28/85 (?) through 1-4-96 and then stopped on 1/4/96, Buspar 10mg p.o./t.i.d.

PAST HISTORY

MEDICAL HISTORY: 1) History of hypertension with coronary artery disease, status post coronary artery bypass grafting 1982. Old EKG in April of 1995 showed sinus rhythm with changes consistent with LVH, non-specific ST-T wave changes and prominent Q-waves in leads 2, 3, and AVF. EKG not seen but reported EKG in old medical record.

2) Renal insufficiency.

3) History of gastroesophageal reflux.

4) History of mycosis fungoides, end-stage. Medical record indicates patient had total body irradiation at one point.

5) History of hypothyroidism.

6) History of urinary incontinence.

MEDICATIONS: See above.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient worked at Hill AFB as a plane mechanic.

HABITS: He does not smoke or drink.

PHYSICAL EXAM

GENERAL: The patient is an elderly male, supine in bed, with Cheyne-Stokes respiration pattern with apnea periods from 20 to40 seconds.

VITAL SIGNS: Admission temperature 97 degrees, pulse 96, respirator 20 per minute, blood pressure 160/100.

C O N T I N U E D . . . REPORT OF CONSULTATION

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 3 . . .

HEENT: PERRL, 2mm to 1mm. Tympanic membranes are dull bilaterally. Nasal mucosa is pink. The mouth is dry. There is erythema of the tongue and palate. No obvious thrush although probably early thrush with severe dry mucosa. The gag reflex is poor.

LUNGS: Diminished breath sounds. There are no wheezes, no rales.

HEART: Regular.

ABDOMEN: Soft, non-tender. There is no hepatosplenomegaly.

GENITALIA: Small, atrophic testicles bilaterally.

RECTAL: Brown stool, hemoccult is pending.

EXTREMITIES: No edema.

DIAGNOSTIC STUDIES

Past laboratory on 10/13/95 – creatinine 1.6, BUN 18, potassium 3.9, serum protein 6.8,albumin 4.1, alkaline phosphatase 58, GGT 20, LDH 214, AST 22, ALT 19, serum iron is 100. WBCs 8000, hematocrit 44.1, platelet count 187,0000. Urinalysis unremarkable. Glycosylated hemoglobin 11.8 on 11/16/95 and 12/4 on 1/5/96. Current laboratory on 1/20/96 – sodium 146, potassium 3.7, chloride 113, CO2 28, anion gap is 5, glucose 162, BUN 18, creatinine 1.3, calcium 9.6, uric acid 6.2, cholesterol 188, triglycerides 75,total protein 6.3, albumin 3.6, total bilirubin 0.7, alkaline phosphatase 61, GGT 18, ALT 15, AST 24, LDH 207, phosphorous 2.6, magnesium 2.1, iron 47, T3 29.6, T4 6.7, T7 1.98. WBC 8500, hematocrit 43.9, platelet count 205,000, MCV 89.5. EKG shows normal sinus rhythm at 89 beats per minute, first degree AV block, prominent Q-waves in 2, 3, and AVF. Non-specific ST-T wave changes, voltage criteria for left ventricular hypertrophy. Chest x-ray pending.

IMPRESSION

Severe dementia with recent increased combativeness, agitation of unclear etiology.
Atherosclerotic cardiovascular disease, status post coronary artery bypass grafting 1982.
History of hypertension, on Hytrin therapy.
Diabetes mellitus, on insulin.

C O N T I N U E D . . .

REPORT OF CONSULTATION

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 4 . . .

Renal insufficiency, fairly stable by reports from October 1995.
History of gastroesophageal reflux disease, unclear past definitions.
History of mycosis fungoides, unknown stage, status post therapy with total body radiation.
History of hypothyroidism, on thyroid replacement and current T4, T7 within normal range; pending TSH
Urinary incontinence.
Decrease anal sphincter tone.
Probably early oral thrush.

RECOMMENDATIONS

Agree with screening laboratories as performed.
Straight catheterized urinalysis to obtain urinalysis and culture and sensitivity.
Advise aspiration precautions with the patient’s diminished mental status and diminished gag reflex.
Consider oxygen saturation for an interval of time during his periodic breathing. Suspect he may desaturate with his apneic spells. His current observed breathing pattern may be secondary to his recent significant sedation. It may suggest a component of central nervous system dysfunction as well.

Thanks for asking me to evaluate Mr. Alldredge

(Signed) David G. Dienhart, M.D.

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
MD

Patient generally unresponsive to questions, lies in bed whimpering, groaning. Initially elevated temperature, now afebrile. White blood cell count within normal limits, sodium increased a little, glucose mildly elevated. Assessment - psychosis not otherwise specified. Plan - continue current care. Robert Weitzel, M.D

1/11/96 Social Services/IT		Individual session - attempted to engage patient in conversation, but patient was sleeping and unresponsive. I will attempt to engage him at a later time. S. Bennion, LCSW

1/11/96 O.T		Occupational therapy will place patient on therapeutic hold today because of agitation and inability to participate in tasks. Occupational therapy will attempt assessment tomorrow. ?

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

24 hour check 1/12/96 0100 T. Scholes

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 RESPIRATORY CARE PULSE OXIMETRY OXYGEN SATURATION Date 1/12/96 0835 ON O2 at ___L/MIN of % SpO2(SaO2)______% OFF O2; SpO2(Sao2) 96% TECH S. Jensen CRT

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

1/12/96 Dietary		Assessment completed. See assessment. Patient not eating presently. Will follow closely to see if appetite improves or if tube feeding will be necessary. (No signature).

1/12/96 MD		Remains quite demented. Combative, mumbles incoherently, cries out. Will not take any medications. Vital signs stable, afebrile. Assessment - psychosis not otherwise specified. Plan - continue current care, increase Haldol. Robert Weitzel, M.D. 1/12/96 Increase Haldol to 10 mg intramuscularly as needed - if patient refusing oral medication (give at morning, 5 p.m. and bedtime, as needed) Thanks, Robert Weitzel, M.D. 1/12/96 1045 noted B. Hardy, RN 1/12/96 Magnetic Resonance Imaging Thanks, Robert Weitzel, M.D. 1/12/96 noted 1045 B. Hardy, RN 1/12/96 1325 Ativan 1 mg intramuscularly now Haldol 5 mg intramuscularly now Telephone order Dr. Weitzel Signed Robert Weitzel, M.D. 1/12/96 B. Hardy, RN 1325 1/12/96 Start intravenous line of D5 2 NS at 100 cc /hr Chem 7 in morning Telephone order Dr. Weitzel Robert Weitzel, M.D. L. Wilson, RN

Ennis Alldredge Overnight Oximetry

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.

May restrain wrists to prevent pulling out IV
Telephone order Dr. Weitzel, MD
Signed Robert Weitzel, M.D.
Noted L. Wilson, RN 1/12/96 2000

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.

1/12/96 Social Services/FT		Late entry for 1/11/96. Phone conversation with patient's wife. Gathered information for psychosocial assessment and discussed treatment plans. (continued, S. Bennion)

1/12/96 Social Services/FT		(continued) Patient's wife expressed how difficult it is to be so far away from him but also admitted that it is a relief to know he's in good hands. Encouraged her to use his hospitalization time for respite. We will try to set up a family session on a Thursday or Friday in the near future. S. Bennion, LCSW

1/12/96 IT		Individual session - patient was sleeping again this evening so I was unable to talk to him. I will visit him again next week to attempt to engage him. S. Bennion, LCSW

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 24 hour check 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

Ennis Alldredge MRI

Ennis Alldredge Chemistries

1/13/96 MD		Patient remains incoherent, unresponsive, crying, needs restraint. Magnetic Resonance Imaging shows left occipital infarction. Urinalysis is pyuric. Glucose level at 40 by Accuchex at 6:00 a.m. He is afebrile, vital signs stable. Chem 7 at 6:10 a.m. reveals glucose of 226, sodium elevated at 148. Potassium adequate. Assessment - cerebral vascular accident. Urinary tract infection. Dehydration. Appears to be quite uncomfortable. Insulin dependent diabetes mellitus, mycoses fungoides. Plan - will attempt to call wife, work out a plan with her. Robert Weitzel, M.D. Addendum- spoke with wife extensively- she feels strongly that no extraordinary measures should be taken to prolong Ennis' life, given the cerebral vascular accident found on MRI. She requests we discontinue IV and give comfort care, let him expire naturally. (continued) Robert Weitzel, M.D.

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 Social Services			Met with family for 1 2 hours. They asked me to call the mortuary in Delta, Utah. I contacted Nichol's Mortuary and they will come within 2 2 to 3 hours of being notified. Family very supportive of measures being taken. They are especially glad that the patient is close by in Davis county so that they don't have to travel to Logan. Attempted to notify Dr. Dienhart and as of 10:10 a.m. he has not answered the page. Will try at home in order to notify of patient's condition and MRI results. Please notify me if any further problems arise. Todd Chambers, LCSW
	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

Cheyne-Stokes respirations, deep chest rales, had been quiet most of night, but appeared agitated this morning - was given extra Morphine sulfate. Slightly febrile. Blood pressure is down. Assessment - close to death. Plan - continue comfort care. Robert Weitzel, M.D.

1/14/96 0600
Morphine sulfate 10 mg intramuscularly now
Telephone order Dr. Weitzel L. Wilson, RN
Signed Robert Weitzel, M.D.
Noted L. Wilson 0600 1/14/96

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

1/14/96
Morphine sulfate 10 mg intramuscularly now
Telephone order Dr. Weitzel B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted B. Hardy, RN 0920 1/14/96

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
		1/14/96 0940 Release body to mortuary per Dr. Weitzel. B. Hardy, RN Signed Robert Weitzel, M.D. 1/14/96 noted B. Hardy, RN 0940
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
		1/14/96 10 a.m. Patient without spontaneous respirations, pulse or blood pressure. Expired 0936 a.m. Spoke with family. S. Hall,? M.D.
1410		Mortuary from Delta, Utah arrived for patient's body. Family gave thanks to staff and departed. B. Hardy, RN

1/15/96 MD

Died this last morning secondary to respiratory arrest, family with him, grief work done. Body released to mortuary. Robert Weitzel, M.D.

1/15/96
Formally discharge patient
Release body to mortuary
Robert Weitzel, M.D.
Noted 1/15/96 1400 S. Hansen, RN

1/15/96 OT

Occupational therapy discharge note: Due to patient condition, occupational therapy was unable to assist patient and no therapy was administered. J.V...? COTA

Ennis Alldredge Medication Administration Record Page 1

Ennis Alldredge Medication Administration Record Page 2

Ennis Alldredge Medication Administration Record Page 3

Ennis Alldredge Medication Administration Record Page 4

Ennis Alldredge Medication Administration Record Page 5

Ennis Alldredge Graphic Chart

DAVIS HOSPITAL & MEDICAL CENTER

DISCHARGE SUMMARY

PATIENT: Alldredge, Ennis

Robert A. Weitzel, M.D.

ADM: 1/ /96

DIS: 1/14/96

HISTORY

The patient was admitted secondary to psychotic behavior. On admission he was started on lente insulin 20 units q a.m. and 5 units q p.m. Accuchecks, Risperdal 1 mg t.i.d., Pepcid 20 mg q day, L-thyroxine 0.1 q a.m., Bumetanide 1 mg q a.m., aspirin 1 po b.i.d., Oxybutynin 5 mg po b.i.d., Micro-K 10 mEq 1 q day, Hytrin 5 mg 1 qhs, DSS 100 mg b.i.d. and Buspar 10 mg t.i.d. He was made DNR on admission.

On admission labs were notable for an elevated sodium and chloride, LDH and low iron. GFTs were normal. Repeat chemistries on the 13^th revealed about he same, increased sodium. Also I should mention his glucoses were consistently elevated. Chest x-ray suggested either some infiltrate or left pleural effusion. CBC on admission was essentially normal except for high number of segmented cells. Urine on admission revealed what appeared to be pyuria, but grew out nothing on C&A.

HOSPITAL COURSE

On the 10^th, Ativan 1 mg and Haldol 10 mg were given IM on a now basis because of agitation. Haldol was ordered if the patient refused or was unable to take his Risperdal. We got a physical therapy consultation regarding his ambulation. He did require restraints throughout hospitalization. On the 12^th, Haldol was increased to 10 mg IM prn. MRI was ordered. It was found that he had a large left occipital stroke. On the 12^th he was quite dehydrated so an IV was started of D5, ½ normal saline at 100 cc an hour. On the 13^th, when it was discovered that he had the stroke and he did appear to be in some pain and discomfort, discussion was held with the family and it was decided to discontinue all extraordinary measures and let him die, giving Morphine and Ativan for comfort. At that point Morphine sulfate was ordered 10mg q 3 hours IM, Ativan 1/2 mg IM q 3 hours. Oral medications were discontinued and lente insulin was decreased. On the 14^th, at 6:00 a.m. he needed another 10 mg of IM Morphine and he got another 10 mg apparently at 9:20 that morning. He expired at 9:36 that morning and doctor from the Emergency Room was kind enough to come up here and pronounce him. He apparently experienced no discomfort toward the end and was able to die peacefully.

continued….

DISCHARGE SUMMARY

Alldredge, Ennis

continued …pg2

Robert A. Weitzel, M.D.

FINAL DIAGNOSIS

Axis I: Psychosis NOS

Axis II: Defer.

Axis III: Cerebrovascular accident, diabetes, mycosis fungoides, hypothyroidism. History of GERD. Renal insufficiency. History of hypertension, history of ASCD and status post CABG in 1982. Alzheimer’s dementia versus multi-infarct dementia.

(Signed) Robert A. Weitzel, M.D.

RAW/kl

D: 1/15/96 10:42

T: 01/16/96 11:45

JOB #6452

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