PHOTO>> << Back To Home Page <<Brief
History Phone Intake
PHOTO>>
Psych Eval History & Physical Discharge Summary Chemistries CBC UA CXR CT
Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment
Physician's Orders Progress Notes Nursing Staff Notes Medication Administration Records
COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
| (12/06/95)
1130 - 1230 Med Note |
Admit note: 93 year old Caucasian female admitted by wheelchair from Holladay Health Care Center. Patient is not oriented and cannot speak coherently. Soon after admit patient began shouting a nonsense syllable over and over, despite one-on-one time by staff. Patient has history of CVA in January 1995 and history of transient ischemic attacks. Patient does not respond to staff; stares blankly or shouts out. Patient ate 25% of lunch with assist from staff; swallows well and can suck through straw. Patient's agitation increased with patient yelling non-stop. (1400 - 1600) Patient medicated with Ativan 2 mg by mouth. Patient's agitation slowly decreased over the next two hours until patient was resting quietly. All consents signed by son, Merlin Larsen. Patient's Living Will and Multidisciplinary Treatment Plan in chart. Call light within reach, patient's mattress on floor per family request. L. Long, RN | |
| 12/6/95
1930 Med |
Behavior - patient very agitated and anxious, patient screaming non-sensical words, patient repositioned, patient continued to scream. Ativan 1 mg intramuscularly given right ventral gluteal. B. Hardy, RN due to patient refusing oral medications and decreased oral intake. B. Hardy, RN | |
| 2300 | Patient calm, able to be weighed, and lungs assessed. Patient has rash under bilateral breasts with right under breast with moles 1.5 cm, irregular shape, dark brown and 1 cm. irregular blackish-brown in color. Area cleansed and powdered with baby powder. Oral care given. Patient very non-compliant with activity of daily living cares - resisting staff's efforts. Patient not able to communicate needs, non-redirectable, not able to identify source of irritation /agitation. Intervention - provided as needed medications, reposition patient, give activities of daily living and oral care, offered fluids and food. Response - patient quiet at this time. Plan - continue to monitor behavior. B. Hardy, RN | |
| 12/7/95
11- 7 |
Free text: night. Slept well with
oxygen at 2 liters per nasal cannula intact, no respiratory distress noted
- moaned loudly twice then slept - diaper changed - fluids refused - oral
care. Right breast remains red - discoriated, position changed, no self
help, no assistance, responds to pain. Shelton, CNA
Behavior - sleepy. Up in chair in conference room. Crying when awake. Needs to be fed by hospital personnel. Not oriented or participating in group. Intervention - fed. Encourage fluids. Spoken to without response. Physical therapy with two people. Response - able to walk a short distance. Drinks slowly. Calls out nonsense words when awake or crying with tears. Plan - encourage and offer fluids frequently ambulate with help. Watch when up in chair, because of history of falls. L. Crooks, CNAs |
|
| 12/7/95
1635 |
Free text - patient acting painful by pulling faces. Medicated with Tylenol 2 tablets for pain. (?) LPN | |
| 1730 | Tylenol effective (?)LPN | |
| 2030 | Free text: Dr. Dienhart notified
of need for history and physical on patient as have not yet heard from
Dr. Taylor yet this shift (paged once). Dr. Dienhart stated to inform him
in morning if still need him to do history and physical. D.Kley, RN
Noted light pink rash under breasts with suspicious moles. Dr. Weitzel notified. No new orders at this time. D. Kley, RN |
|
| 2215 | Behavior - patient has been sobbing without tears much of this shift, at times put head down in hands on table. Rambles and repeats nonsensical statements. Very repetitive. Required to be fed by nurse. Stiffened up, almost sliding out of chair several times. Intervention - administered medications as ordered - difficulty getting down evening (HS) meds. Provided groups. Provided quiet environment, one -on -one. Response - patient sobbed without tears most of shift when (continued) D. Kley, RN | |
| 12/7/95
2215 |
(continued) up. Resting quietly in bed with eyes closed at this time. Has not triggered bed alarm this shift. Stiffens up; sliding down in chair when up - Dr. Weitzel ordered physical therapist to get foam wedge for chair. Seems to have no insight. Confused. Plan - continue to administer medications as ordered. Provide groups, one-on-one as needed. Monitor closely, high fall risk. Bed alarm. Quiet low stimuli environment. D. Kley, RN | |
| 12/8/95
0700 |
Free text: patient slept all shift. Patient turned three times. Incontinent once. Very restful night. Ables, CNA | |||
| 0700 - 1500 | Behavior - patient was alert but disoriented all shift. Alternately crying or shouting nonsense words and phrases, such as AFeel and see!@AFeel it!@AFeel, can see!@ Intervention - offered one-on-one, groups, meals, movie. Response - patient wouldn=t respond to staff requests, needed to be fed and all activities of daily living needed extensive assist. Patient was agitated, yelling most of shift. Plan - therapeutic, safe environment. Medications as ordered. L. Long, R.N. | |||
| 12/8/95
3p - 11p |
Problem: altered thought process.
Behavior: patient is not interactive with her environment. Multiple self-stimulation behaviors including: rocking, repetitive rhythmic speech, and echolalia, moaning and crying frequently. Intervention - administer Risperdol and Klonopin as ordered. Monitor and document behaviors and response to medication. Provide safe environment. Response - patient remained acutely distressed until 2000. Crying inconsolably in bed. Provided backrub for 20 minutes. Patient was able to quiet for one hour. Awoke again. Crying uncontrollably. Given Ativan 1 mg intramuscularly. Much calmer in one-half hour. One hour later patient is resting quietly, respirations slow, deep and regular - not roused by every 15 minute nursing checks. Plan - continue current interventions. L. Wilson, RN |
|
| 12/9/95 | PRN Ativan given for agitation at 0300. Effective for approximately 1 2 hours. T. Scholl, RN | |
| 0645 | Free text: patient awake and crying out most of night. After being turned from her back to her left side, patient repositioned herself to her right side. Towards early morning hours patient started to sleep. Appeared to be somewhat in a relaxed state. Ables, CNA | |
| (7a – 3p) | Behavior - Judith slept most of day, it was hard to wake her even for meals, she ate very poorly. Intervention - offered groups and meals. Response - she slept through groups but when she was awake she repeated words over and over. Plan - continue to offer groups and meals. Angie Kennedy, CNA | |
| 12/9/95
3p - 11p |
Altered thought process
Behavior - patient continues to demonstrate very regressed /self-stimulation behaviors. Echolalia persists. This behavior increases in frequency, intensity, and volume, as shift progresses. Intervention - monitor and document behavior. Ativan 2 mg by mouth at 1930. without significant effect. Ativan 2 mg intramuscularly at 2000 per order of Dr. Weitzel. Provide safe environment. Response - patient remains awake and talking repetitively to self as of 2300. Volume of speech has markedly decreased and the patient is no longer tearful. L. Wilson, RN Plan - continue interventions as specified above. L. Wilson, RN |
|
| 12/10/95
0600 |
Free text - patient was very noisy when staff relieved 3 to 11 shift, patient continued to yell out for two hours. Patient finally fell asleep and is currently sleeping well. S. Thomas, CNA | |
| Behavior - patient up in chair, nonresponsive, nonverbal, is not eating, sleeping most of morning. Intervention - nurse gave medications as ordered, provided quiet environment. Response - non-responsive; patient is alert and oriented x 3. Plan - provide a safe and (?) environment according to treatment plan. Lee, CNA | ||
| 12/10/95
3p - 11p |
Problem: altered thought process
Behavior - patient was somnolent most of the shift. Respirations slow and regular. Rate 16 - 18. Family visited and attended a lengthy teaching session with this RNregarding patient's current medications and expected course of treatment/ care during this hospital stay. Family repeated the request that patient be made comfortable and requests that she be a "Do Not Resuscitate". Patient ate dinner with feeding by staff. Roused at 2000 and began to moan and cry. Intervention - bedtime medications given with calming effect after tearful episode. Response - Family voiced understanding of purpose of all medications. Understanding of the purpose/goal of comfort measures was also articulated by family. Plan - continue current treatment. Administer medication. Provide safe environment. Reinforce family education. L.Wilson, RN |
|
| 12/11/95
11 - 7 |
Patient rested quietly thorughout shift. Respirations slow, deep and regular. Not roused by every 15 minute nursing checks. L. Wilson, RN | |
| (7a – 3p) | Behavior - patient has been asleep during shift. Patient has been unresponsive. Patient has had to be put on oxygen and suctioned times one. Patient has decreased health wise during shift. Intervention - offer patient meals, groups, one-on-one. Response - patient ate 10% of breakfast and none of lunch. Patient didn't attend group because patient was unresponsive and sleeping. Patient would not arouse during shift. Plan - follow care plan. Check and record patient health status. T. Sprague, CNA | |
| 12/11/95
1530 |
Vital signs - temperature 98.4, pulse 84, respirations 18, blood pressure 108/82. Patient continues with oxygen at 3 liters per nasal cannula. Patient's respirations even, with open mouth breathing. Oral care given and large mucous secretions removed. Patient able to close mouth and breath through nares; circulation - less than 3 second capillary refill in all four extremities. Patient responded to tactile touch by opening eyes. Right eye remained open. Patient not able to respond to hand grip, lungs decreased in bases bilaterally. B. Hardy, RN | |
| 1730 | Patient positioned upright, patient able to swallow two spoonfuls of mashed potatoes, drink 4 oz of apple juice through a straw, and 4 oz of high calorie drink through straw. Patient able to keep right eye open during oral intake. Patient positioned on side, 1700 medication given crushed in mashed potatoes. Patient with unlabored breathing, skin warm to touch. B. Hardy, RN | |
| 12/11/95
2100 |
(continued) Intervention - Monitored patient status. Response - patient shows no signs of distress. Patient continues to need full care, declining tactile responses. No screaming. No agitation. Plan - monitor patient status. Provide cares. B. Hardy, RN | |
| 12/12/95
11 - 7 |
Night shift free text - patient is somnolent, snoring often. Skin care provided as needed for this bed-bound patient. Turned and repositioned and range of joint motion provided every two hours. Patient remains essentially unresponsive to environment. L. Wilson, RN | |
| 7 - 3 | Problem #1 Behavior - patient was lethargic most of day interspersed with occasional periods of alertness. Patient was tearful and crying out in evening. Intervention - patient given safety (geriatric chair), one-on-one time for activity of daily living, medications given, encouraged verbalization of feelings. Response - patient responded "No" when asked if in pain during crying out episode. Patient demonstrated echolalia: when asked question would repeat questions. Plan - continue medications, one-on-one time, encourage verbalization of feelings. R. Clark, LPN | |
| 12/12/95 | Behavior - patient was verbalizing a jumble of words in a rhythmic pattern. Patient was positioned in the Geriatric Chair with no physical movement. Patient taken to day room and positioned at table with other patients. Patient opened eyes and when asked "does patient want to be called by another name?" Patient stated very clearly "yes". Notation on chart states patient likes to be called Judy or Viola. Patient took 1700 medications well with food but was very drowsy and sleeping; could not arouse for 2100 and 2000 medications. Intervention - encourage patient to interact with tactile touching and verbal stimulus, provided one-on-one and evening cares. Response - patient was alert for a very short time when in day room only. Plan - monitor alertness and increase interaction out of room. B. Hardy, RN | |
| 12/13/95
11 - 7 |
Free text, nights - slept well with head of bed elevaated. Skin cold to touch. Diaper changed. No verbal communication during night, responds only to pain - respirations labored - frequent positioning. Coccyx red. Shelton, CNA | |
| 1400 | Behavior - patient exhibited no agitation behavior. Patient exhibited no delusional behavior. Patient slept through most of shift, but woke up for meals. Intervention - offered one-on-one groups. Assist with meals. Took 70% breakfast and lunch. Assist with activities of daily living . Response - no efforts made to feed self or do activities of daily living. Lethargic. Not oriented. Does not make attempt to move in chair. Sleeps 80% of day. Took medications with meals. Plan - continue to assist with meals. Push fluids. Encourage patient to interact. Monitor vital signs and behavior and provide therapeutic environment. Assist with medications as needed. | |
| 12/13/95
(unreadable time) |
Behavior - patient has not been agitated on shift. Patient has talk very repetitious and outspoken. Intervention - patient has been offered meals, snacks, fluids and group. Response - patient ate good for dinner, patient has not been able to participate in group due to being disruptive. Patient has wanted to get up and walk. Patient was walked with assistance. Patient did not walk far, but patient walked a lot better than staff thought she could. Plan - patient needs to stay awake. Patient needs to be less disruptive so that she can attend and participate in more groups. Sherry Thomas, CNA | |
| PRN Med
2000 |
Free text: Milk of Magnesia 30 cc given due to constipation. Results pending. B. Hardy, RN | |
| 12/14/95
11 - 7 |
Free text: nights. Slept well. No arousal during checks. O. Shelton, CNA | |
| 1215 | Behavior - has met goal to stay awake during groups - has had some delusions and inappropriate behavior - yelling out and clapping. Intervention - attended groups - was extremely sleepy this morning, but has woken up as the day went on. Response - ate lunch very well and was moderately alert; met her goal set to eat at 30% meals. Plan - to keep patient involved in groups and at meals - to discourage sleep during the day and to encourage oral intake. Huggins, CNA | |
| 12/14/95
2200 |
Problem 1 Behavior - patient showed an absence in agitation but was expressing confusion. Intervention - patient was offered the opportunity to go to groups. Staff gave patient one-on-one sessions periodically. Patient was fed meals. Patient failed to open eyes for the entire meal. Response - patient responded in a repetitive behavior. Patient interacted with group, but was highly irritating to them, for her repetitious sentence was annoying. Patient ate well when being fed. After patient had nightly cares she declined in repetitious wordings. Plan - patient needs to interact in short intervals. Patient needs more rest time for her mind can't take so much at one session. Patient should be encouraged to feed self with minimal assistance. Patient needs to wake up more to what's around. Lynette Winn, CNA | |
| 12/15/95
0630 |
Free text: patient slept well, turned every two hours during shift. No problems noted at this time. Ables, CNA. | |
| 1515 | Behavior - patient has been very tearful and has slept through most of the shift. Patient has talked to staff and has answered the questions directed toward her and was answering them correctly and made sense. Intervention - offered patient all meals and groups/activities. Patient was given an enema during the afternoon. Response - patient ate 80% of all meals and attended groups in the morning but not in the evening. Patient did not participate but did attend. Patient has had good results from the enema. Plan - continue to encourage patient to keep eating and stay awake during groups and participate. N. Hancock, CNA | |
| Med
1100 |
Dulcolax suppository 1 given for constipation with good results. E. Cozzins, RN | |
| 12/15/95
7p - 11p |
Altered thought process
Behavior - patient is calm and cooperative. She is alert and attentive to her environment. Makes eye contact with staff and attempts to offer appropriate verbal comments. Frustrated by expressive aphasia. Intervention - provide safe, structured environment. Provide medications as ordered and monitor effects. Observe and document behavior. Response - patient is more calm and alert today. Ate well at dinner and attempted to feed herself. Compliant with all medications (crushed in applesauce). Interaction with others are more meaningful. Plan - continue current interventions as specified above. L. Wilson, RN |
|
| 12/16/95
11 - 7 |
Patient appeared to sleep quietly throughout the night with respirations even and unlabored. No problems noted. T. Scholl, RN | |
| 1330 | Patient agitated, crying and calling out for husband. Stated Awhy did he have to get old?@ Patient given feedback, positive calm environment, without much effect. Still continues to cry out. Patient medicated with Ativan 2 mg by mouth. J. Jensen, LPN | |
| 1410 | Good effect from Ativan, patient calm, appears relaxed, in bed with eyes closed, no more calling out. J. Jensen, LPN | |
| # 1
1500 |
Behavior - patient became agitated times 1 during shift. Patient was lethargic at start of shift; increased alertness as shift progressed. Patient sat through entire movie and expressed emotion at appropriate times. Patient fed self lunch. Patient increased agitation after lunch wanting to leave the place, attempting to ambulate on own. Staff assisted patient to feet and ambulated patient with two-person assist. Patient made statements: "I go from one place to another" and "I can go where I was yesterday." Family in to visit(continued) B. Hardy, RN | |
| 12/16/95
1500 |
(continued) family states "patient is much improved" from last week and hopes this progress will continue. Intervention - gave prn medications. Provided assistance with ambulation. One -on-one to allow patient to verbalize frustration. Response - patient vocalized a lot but unsensical rambling at times. Patient needed one-on-one to remain seated and safe. Plan - continue to provide safe environment; monitor behavior. B. Hardy, RN | |
| 2145 | Behavior - patient has not yelled out this shift. One very short crying episode for no apparent reason. Very alert this shift. Fed self. Affect appropriate. Actively participated in group, answering questions appropriately. Ambulated with assist in halls times 2 this shift at patient=s request. Alert and oriented but searched for date on chalkboard. Refused bedtime medications, asleep. Interventions - administered medications as ordered. Provided group and one-on -one. Oriented to place and time as needed. Verbally redirected when crying. Response - patient active in group. Bright, alert. (continued) D. Kley, RN | |
| 12/16/95
2145 |
(continued) verbally redirectable when crying. Took all medications this shift as ordered except bedtime (was asleep, refused). Sat up to table, fed self, good oral intake. Ambulated in halls times 2 with assist. Plan - continue to administer medications as ordered. Provide groups. Reorient as needed. Verbally redirect as needed for yelling out or crying. D. Kley, RN | |
| 12/17/95
0700 |
Patient has slept most of night without complaint offered, and no distress. Answers nurse appropriately without anxiety noted. Both side rails up. K. Burnette, LPN | |
| 1400 | Patient given 0800 Betagan. Medication was not available at time it was due, but when received from pharmacy it was administered. C. Howe, LPN | |
| 1450 | Behavior - patient has been very talkative and confused during this shift. Patient has been hallucinating saying that there were caskets in the room and that we were in a cemetery, and that there is a cat on the TV looking at her. Intervention - offered patient all meals and groups /activities. Response - patient ate 90% of all meals and attended all groups. Patient has been redirected and it has not worked very well. Patient only became more confused. Plan - continue to redirect patient to her surroundings and encourage patient to interact more with other patients. N. Hancock, CNA | |
| 12/17/95
2100 |
Behavior - patient has been alert, verbalizes needs. Participated in group. Confused - oriented only to self. Spoke with daughter on phone, became tearful after hanging up, stating "I haven't seen her since she was a little girl." On and off tearfulness for next hour until forgot phone call. No agitation observed this shift. Ambulates with one or two person assistance. Intervention - medications administered as ordered, groups provided, behaviors monitored. Provide a structured safe environment. Family educated regarding signs and symptoms of illness and medication education. Response - patient has been alert, redirectable, one crying episode, no agitation. Plan - continue to administer medications as ordered. Provide groups. Provide structured safe environment. Monitored behaviors. D.Kley, RN | |
| 12/18/95
0600 |
Patient has slept most of the night. Did awake early this morning, confused, taking off her diaper and gown, pleasant, cooperative, no distress. Call light in reach - bed check patent. Stacey Kendall, LPN | |
| 1510 | Behavior - patient has been quiet and has hallucinated during this shift. Patient saw crutches in the corner and wanted them, patient saw caskets again. Patient was talking to a man named Frederick and wanted him to get her crutches. Intervention - offered patient all meals and groups/activities. Response - patient ate 90% of breakfast and 100% of lunch. Patient attended all groups and participated well in these. Offered patient redirection to her surroundings. Plan - continue to redirect patient to surroundings and encourage patient to interact more. N. Hancock, CNA | |
| 12/18/95
Med Note |
Free text: Patient has become increasingly agitated since shift change at 1500; trying to get up without assist; yelling in worried, angry voice "will you let me, why won't you let me!?" and other nonsense sentence fragments, or repeating phrases she just heard the staff utter. Patient medicated with Ativan 2 mg by mouth. L. Long, RN | |
| 1930
Med Note |
Free text: patient still agitated - yelling, crying, trying to get out of bed. L. Long, RN | |
| 1500-2300 | Behavior - patient disoriented, demented, and agitated all shift. After getting eye drops administered by RN, patient tried to put popcorn in her eye, saying "should I put it in now?" Intervention - offered movie, meal, one-on-one, medications as ordered, assist with all activities of living. Response - patient couldn't focus on movie or any activity for long. Would try to get up, or reach for invisible objects, or play with objects within reach. Patient fed self. Patient was continent this shift. Plan - therapeutic safe environment, assist with activities of daily living, constant supervision. L. Long, RN | |
| 12/19/95 11-7 |
Free text, nights: slept throughout the night without arousal. Opened eyes to treatment. No verbal response offered. D. Shelton, CNA | |
1400 |
Behavior- patient has only had one episode of yelling that lasted only about 10 minutes and was not as loud as usual. Intervention-support. One-on-one time. Medications as per Doctor, therapeutic environment. Response-ate better but had to be fed. Patient has called people by other names. Confused. Plan - medications as per Doctor. Therapeutic environment. E. Cozzins, RN | |
| 12/19/95
(unreadable time) |
Problem #1. Behavior - patient has not had any delusional episodes. Patient has not been yelling out. Patient has been very tearful on shift. Intervention - patient was offered meals, snacks, fluids, and group. Response - patient ate well at mealtime. Patient attended group. Patient began to cry before dinner. Patient then stopped after dinner. Patient has been trying to get out of her chair. Plan - patient needs need redirection.. Patient needs to be in a safe, supervised place. S. Thomas, CNA | |
| 12/20/95 11 - 7 |
Free text: nights. Eyes closed all night, woke briefly when vital signs taken. No verbal complaints. Shelton, CNA | |
| (7a – 3p) | Behavior: Patient has been asleep at times and awake at others in group. Patient has been tearful today when awake. Patient has been cooperative with staff. Intervention - offered patient, group, meals. Response - patient needed maximum assist with ADL's Patient ate 100% of breakfast and 80% of lunch. Patient attended group but was lethargic at times. Plan - follow care plan, encourage patient to stay awake. T. Sprague, CNA | |
| 12/20/95 2205 |
Patient somewhat tearful this shift. Patient attended groups and activities, although she really did not participate. Patient ate about 85% of evening meal. Intervention - provide a safe, therapeutic environment. Encourage patient to try and feed herself. Response - patient does lately well feeding herself. Patient not real responsive. Plan - continue with medications per doctor's orders. Keep as comfortable as possible. Ables, CNA | |
| 12/21/95 11 - 7 |
Free text: nights. Slept well during night. No complaints when aroused. Shelton, CNA | |
| 1450 | Behavior - patient has been tearful and confused during this shift. Patient has not hallucinated during this shift. Intervention - offered patient all meals and groups/activities. Response - patient ate 70% of breakfast and 100% of lunch. Patient attended all groups ansd participated well. Plan - continue to encourage patient to be cooperative and help patient to be oriented to surroundings. N. Hancock, CNA | |
| 12/21/95 2150 |
Behavior - patient has been showing tearful episodes on this shift. Patient has also been singing Christmas songs. Intervention - offer patient activities, one-on-one time and meals. Response - during group patient had tearful episode, she said "I can't do anything anymore." Patient ate 100% of supper. Plan - one-on-one time with patient, encourage participation in group activities. N. Beech, CNA | |
| 12/22/95 0645 |
Free text: patient slept all shift. Appeared to be relaxed. Voided sufficient amount, no problems noted at this time. Ables, CNA | |
| 1535 | Behavior - patient has been very quiet and has not wanted to talk to staff or other patients. Patient has not participated in groups. Intervention - offered patient all meals and groups / activities. Response - patient ate 100% of breakfast and 30% of lunch. Patient attended all groups but did participate very well. Plan - continue to encourage patient to interact with staff and patients. N. Hancock, CNA | |
| 2215 | Behavior - patient has been very quiet this shift and nonverbal. Has only said a few words and appeared to have difficulty forming those words. Distracted, staring at ceiling. Nystagmus, has tremors. Weak - 2 person assist leaning to right with ambulation. 1+ right sided pedal edema. Grips equal and strong. Poor oral intake. Stiff movements. No crying episodes this shift. Restless (con't) | |
| 12/22/95 2215 |
(continued) in bed since put to bed - attempting to strip clothing. Dr. Weitzel aware of patient's condition. Intervention - medications held this shift as ordered. Monitored closely. Assisted as needed. Group provided. Response - patient has been distracted, staring, very quiet this shift - has not verbalized needs. Required 2 person assist with ambulation. Poor oral intake. Did not interact in group. Plan - continue to monitor. Assist as needed. Monitor/ document behaviors. Notify medical doctor as indicated. D. Kley, RN | |
| 12/23/95 0600 |
Free text: patient was awake in bed until 0430 but was quiet and calm, just lying with eyes open. Patient slept from 0430 to change of shift, with respirations even and unlabored. Patient voided twice in diaper. L. Long, R.N. | |
| (7a –3p) | Behavior - patient has been alert all shift. Patient has not been responding to questions asked to her. Patient has been cooperative with staff. Patient has been continent all shift. Intervention - offered patient activities of daily living group and meals. Response - patient needed medium assistance with activities of daily living. Patient attended group and stayed awake through the movie. Patient ate 90% of breakfast and 10% of lunch. Patient needed help while eating. Plan - follow care plan, encourage patient to interact. T. Sprague, CNA | |
| 12/23/95 1500 - 2300 |
Behavior - patient was mute this shift, in Geriatric Chair in day room with eyes open but not tracking activities such as movie or group. Patient had totally flat affect and needed assistance with all activities of daily living. Patient incontinent of urine times 2 this shift. Intervention - offered movie, group, one-on-one assist with all activities, medications as ordered. Response - patient attended group and movie but was unresponsive to questions, sat staring vacantly. Plan - therapeutic safe environment, medications as ordered. L. Long, RN | |
| 12/24/95 0600 |
Free text - patient has slept well all shift. Patient has been incontinent none. Sherry Thomas, CNA | |
| (7-3) | Behavior - patient has been lethargic and hard to arouse all shift. Patient has episodes of crying twice during shift. Patient was cooperative with transfers. Intervention - offer patient activities of daily living, group, meals. Response - patient needed maximum assist with activities of daily living. Patient was incontinent once during shift. Patient attended activities but was lethargic. Patient ate 70% of breakfast and 40% of lunch. Plan - follow care plan, encourage patient to stay awake. T. Sprague, CNA | |
| 12/24/95 2030 |
PRN Fleets enema given patient with distended abdomen, hypoactive bowel sounds all four quadrants. B. Hardy, RN | |
| 2230 | Good results with enema - large brown hard stool with liquid (unreadable word) B. Hardy, RN | |
| 2245 | Problem 1: Behavior - patient was very sleepy she didn't participate in activity cause she was tired. Patient showed no signs of agitation. Intervention - patient took a nap, when waking for dinner was still tired. She was asked by staff questions and she showed no signs of answering. Response - patient very tired. Ate 30% of meal and wanted to go to bed. Plan - patient must interact more to keep body moving to stay awake. Patient should attend groups and should have one-on-one talks with staff. L. Winn, CNA | |
| 12/25/95 0645 |
Free text - patient has slept well through shift. Patient has been incontinent once, and incontinent of stool once. Thomas, CNA | |
| 0700 - 1500 | Behavior - patient became increasingly alert as shift progressed, made no verbalization, although she would turn her head to left or right when asked. Intervention - offered meals, groups, one-on-one, movie. Patient was medicated with morphine sulfate 2mg. intramuscularly at 0730, 0930, and 1130, with patient's level of alertness increasing throughout the morning and continuing throughout the shift, although (Response) - patient would not speak but watched the movie and remained awake and alert. Plan - therapeutic safe environment, medications as ordered, devise flash card system to facilitate communication. L. Long, RN | |
| 12/25/95 | Behavior - Patient had no agitated behaviors. Patient did not communicate verbally. Patient became very tearful during wrap-up group when staff held patient's hand. Patient refused to eat dinner, took towel off lap and placed it over tray and pushed tray away. Patient would not allow staff to feed her which she communicated by clenching her teeth. Patient spit oral medications out which were crushed and placed in applesauce. Patient placed in bed with two side rails and bed monitor in place. Patient rigid. Keeping eyes open, cold ice applied to extremities and forehead. Patient responded with decrease in facial tightness and movement of eyes. Patient refuses water. Intervention - provided wrap-up group, oral medications. Response - patient remains rigid and staring. Respirations even and unlabored. Plan - continue to monitor behavior. B. Hardy, RN | |
| 12/26/95
11 - 7 |
Seizure activity - patient checked frequently throughout the night; resting quietly with eyes open - respirations even and unlabored. Would track with eyes when spoken to. At 0540 patient began to grunt and gradually patient's right side began to jerk - right leg, arm, face, etc. Vital signs - blood pressure 160/100, pulse 92, temperature 99.1. House supervisor notified. M.D. (Dr. Dienhart notified) and IV of D5 started as ordered, Ativan 3 mg IV given and no improvement noted. Dr. Dienhart called. Additional 1 mg Ativan given and patient calmed - no jerking - respirations free and easy. IV changed to normal saline and Dilantin, 1 gm infusing over 40 minutes. Blood pressure 104/60, respirations 20. Dr. Dienhart in to see patient. Oxygen at 2 liters per nasal cannula. To X-ray department by cart for CT scan. Oxygen saturation 90% on 2 liters. EKG done. IV changed to D5 2 NS at 70cc per hour. Patient returned from X-ray. IV discontinued. Blood pressure 70/40. Periods of apnea. Dr. Weitzel notified. T. Scholl, RN | |
| 12/26/95
|
Behavior - patient has had no agitation this shift. Patient remained in bed entire shift. Patient with oxygen at 2 liters. No distress noted. Patient opened eyes occasionally during cares. No verbalization, patient remains very lethargic. Patient able to eat 60% of meals with staff increased encouragement and small liquified portions given. Patient not able to turn self, staff repositioned every 2 hours and gave sips of water. Patient does not moan or make any verbal communications. Intervention - provide all cares and attempted to arouse patient with verbal and physical stimuli. Response - patient does not response to stimulus, does open eyes occasionally during cares. Plan - continue to monitor and report condition to doctor. B. Hardy, RN | |
| (Entire page crossed out) | (No date) | |
| 12/27/95 11 - 7 |
Free text: Night. Slept well - aroused easily to positioning every 2 hours, diaper changed x 2. Taking liquids when forced. Need to remind her to swallow. This morning when given liquids, stated "no, no, no" however, did take. No seizure-like activity noted. Oxygen 2 liters per nasal cannula continued and intact. Shelton, CNA | |
| (7-3) | Behavior - patient has been lethargic today. Patient was sleepy all shift. Patient was hard to arouse for group and meals. Patient did mumble words that were hard to understand. Intervention - offered patient activities of daily living, meals and group. Response - patient needed maximum assistance with activities of daily living. Patient ate 30% of breakfast and 20% of lunch. Patient attended group but as too lethargic to participate. Plan - follow care plan, encourage patient to stay awake. T. Sprague, CNA | |
| 12/27/95
2130 |
Behavior - patient has had two episodes of screaming and was quite sleepy the rest of the shift. Intervention - attended all groups but was very lethargic, and did not participate. Ate 35% of supper. Response - when patient did awaken after being aroused several times - she was quite anxious and had two episodes of screaming when it was hard to redirect that behavior. Plan - to attend groups and stay awake and participate - orient to place and time when patient becomes disoriented - to increase oral intake. R. Huggins, CNA | |
| 12/28/95 11p - 7 a |
Free text: patient slept quietly throughout the night. Oxygen at 2 liters per minute by nasal cannula. Patient frequently removing oxygen - staff putting back on. Bed check monitor in place. Both side rails up. T. Scholl, RN | |
| 1500 | Behavior - patient has been quiet and non-responsive during this shift. Patient has not participated or interacted with any staff or peers. Intervention - offered patient all meals and groups/activities. Response - patient ate 40% of breakfast and 60% of lunch. Patient did attend all groups, but did not participate. Plan - continue to encourage patient to stay awake and interact more during the shift. N. Hancock, CNA | |
| 12/28/95 1730 |
Free text: decreased lung sounds throughout, however, patient won=t breathe deeply when instructed. D. Kley, RN | |
| 2230 | Behavior - patient has been alert, quiet this shift. Took medications as ordered. Did not respond to questions appropriately, blank stares. Did not attend group - visited with family. Very slow to respond (i.e., when name called - turns head slowly towards speaker after long delay). Intervention - administered medications as ordered. Provided quiet, low stimuli, structured environment. Offered groups. Monitored. Encouraged to verbalize feelings. Response - patient slow to respond. Quiet. Took medications as ordered. Plan - continue with medications as ordered. Provide group. Monitor behaviors/ condition - report to doctor as indicated. D. Kley, RN | |
| 12/29/95
11p - 7a |
Free text - patient awake several times during night. No signs or symptoms of pain or distress noted. Otherwise appeared to sleep quietly. Oxygen saturations 95% on room air. Side rails up. Bed check monitor in place. T. Scholl, RN | |
| 1430 | Behavior - patient has had a flat affect all day. Intervention - offered patient meal, groups, redirection. Response - patient ate 60% of breakfast and 70% of lunch. Patient attends groups but does not track groups. Plan - to continue to redirect when she becomes confused. S. Perry, CNA | |
| 12/29/95 2200 |
Behavior - patient attended groups but slept through them; at 1600 patient began a 5 hour cycle of severe emesis seven times, and diaphoretic skin to touch. Vital signs taken - temperature rose to 99.5 at 2200. Large amounts of emesis, changed bed three times. Was put to bed at 1700 - did not eat any dinner and vomited medications. Interventions - attended group at beginning of shift - did not participate. Response - emesis continued after being put in bed, raised head of bed to 90 degrees to prevent choking, was unable to keep anything down, including liquids. Is presently sleeping, no emesis since 2100. Will continue to monitor. Plan - to encourage attendance and interaction in group. R. Huggins, CNA | |
| 1900 | Paged Dr. Weitzel to notify him of patient's persistent nausea and vomiting. Vital signs stable. Patient is awake. Vomitus is clear to yellow with food particles. (L.Wilson, RN) | |
| 2000 | Paged Dr. Weitzel again. Patient continues to vomit. (L. Wilson, RN) | |
| 2130 | Paged Dr. Weitzel again. "Patient continues to vomit." Has been without oral intake since 1730, medication held. L. Wilson, RN | |
| 12/30/95 2400 |
Free text - patient vomiting emesis - coffee grounds-like in appearance with pasty texture. Vital signs stable. Dr. Weitzel and Dr. Dienhart paged. Patient cleaned up and bedding changed. T. Scholl, RN | |
| 0100 | Patient vomited again - emesis similar in appearance. Dr. Weitzel paged again. Nursing supervisor informed. T. Scholl, RN | |
| 0330 | Dr. Weitzel called - aware of patient's condition. T. Scholl, RN | |
| 0530 | Patient vomited again. Continues with head elevated and head to side. Vital signs stable - temperature 99.4, pulse 70, respirations 18, blood pressure 112/80. T. Scholl, R.N. | |
| 0730 0855 |
Behavior - patient unresponsive to verbal stimuli,
patient weak. Heart rate irregular, respirations even, nonlabored at this
time. Patient diaper changed once, with urine output. Patient not able to
orally intake. (B.Hardy, RN)
Dr. Weitzel notified of patient condition. Doctor stated he would be arriving soon. B. Hardy, RN | |
| 0920 | Patient with approximately 100 cc emesis - dark brown coffee grounds coming from nares and mouth. (continued) B. Hardy, RN | |
| 12/30/95 0920 |
(continued) Patient cleansed - no response. Heart rate tachycardic and irregular, respirations even nonlabored, shallow. B. Hardy, RN | |
| 1130 | Patient family in to see patient. Aware of physical status change. Family stated they want Do Not Resuscitate status maintained and comfort measures given. B. Hardy, RN | |
| 1400 | Dr. Weitzel ordered morphine sulfate IM to be given every 4 hours round the clock. Patient not orally intaking. Oral care given and position changed. B. Hardy, RN | |
| 12/30/95 1650 |
Lung sounds decreased in bases bilaterally. D. Kley,
RN Patient respirations irregular, Cheyne-Stoking. Opens eyes to name. Resting quietly. D. Kley, RN | |
| 2000 | Patient continues to rest quietly in bed. Respirations even. Responds with eye opening to name. Lethargic, with drawn appearance. Has taken no oral intake this shift. Turned every 2 hours, frequent oral care done. D. Kley, RN | |
| 2100 | Called son, gave status report on patient's condition. Son (Merlin) stressed that Aonly wished to keep her comfortable.@ D. Kley, RN | |
| 2240 | Behavior - patient has been resting quietly this shift. Respirations slightly labored at times. Cheyne-Stoking at times. Opens eyes to name. Does not respond verbally. Took no oral intake. Intervention - medications held this shift as do not feel patient alert enough to swallow. Patient turned every 2 hours with frequent oral care given. Monitored frequently and closely. Response - patient has appeared to be resting comfortably this shift, no restlessness noted. No skin breakdown- D. Kley, RN | |
| 12/30/95 2240 |
(continued) noted. Opens eyes to name. Does not respond verbally. No oral intake this shift. Plan - continue to administer intramuscular morphine as ordered. Turn every 2 hours. Provide frequent oral care. Keep doctor/family aware of patient's status. Monitor for skin breakdown. Provide comfort measures. D. Kley, RN | |
| 12/31/95 | (con't) Son concerned that family members were flying in from out of state due to night shift nurse's report to son on 12/30/95. Vital signs - temperature 99.1, blood pressure 88/52, pulse 60, respirations 16. B. Hardy, RN | |
| 0945 | Patient turned and positioned. Oral care provided, no urine output. Patient not responding to tactile or verbal stimuli. Respirations even. Patient continues with eyes open. B. Hardy, RN | |
| 1145 | Patient turned and positioned. No oral intake. No distress noted. Family members in to visit. Oral care provided. B. Hardy, RN | |
| 1430 | Patient turned and positioned. Oral care given. Patient unresponsive to tactile touch. Vital signs - blood pressure 98/50, respirations 22, pulse 88, temperature 99.2. Family in to visit and aware of patient's medical status. B. Hardy, RN Intervention - provided activities of daily living and family education. Response - family verbalized understanding. Patient unresponsive. Plan - continue to provide care and comfort measures. B. Hardy, RN | |
| 12/31/95 1500-2300 NSG |
Evening shift nursing notes: Behavior - patient has been unresponsive this shift except to make small gutteral noise when intramuscular shots given per doctor's orders. Intervention - offered oral and peri care, turned patient every 2 hours, medications as per doctor's orders, vital signs every 4 hours. Response - patient does not respond to verbal stimuli. Stares blankly or sleeps with eyes closed, no response to gentle shaking. Plan - comfort measures. L. Long, RN | |
| 1830 NSG |
Free text - vital signs: blood pressure 118/60, respirations 12, pulse 72, temperature 96.7. Morphine sulfate 5 mg intramuscular given in right gluteus. L. Long, RN | |
| 1930 NSG |
Free text - vital signs: blood pressure 115/65, respirations 12, pulse 92, temperature 97.3. Morphine sulfate 5 mg intramuscular given in left gluteus per doctor=s now order. Patient moaning slightly when turned for injection. L. Long, RN | |
| 2230 NSG |
Free text - vital signs: blood pressure 120/65, respirations 12, pulse 100, temperature 99.4. Morphine sulfate 5 mg intramuscular given in right gluteus. Respirations even at 12 per minute. L. Long, RN | |
| 1/1/96 11 - 7 |
Night shift free text note - patient continues to exhibit Cheyne-Stokes respirations. Periods of apnea 15-20 seconds. Has reflexive hand grasp but this is only clear response to environmental stimuli. Temperature maximum 100.4 at midnight. 97.6 at 0230. Morphine sulfate 5 mg given every 4 hours intramuscularly for comfort. Pulse maximum rate 120, lowest 60. Blood pressure 120/60 to 130/60. Turned every 2 hours. Duoderm applied to reddened area at coccyx . Area provided is 1 2 to 2 inch square. Skin is not abraded or broken. Mouth care and comfort measures as needed. No family visitors tonight. L. Wilson, RN | |
| 0730 | Patient repositioned and oral care given. Skin warm to touch. Patient rigid with extremity movement. Diaper dry. B. Hardy, RN | |
| 0935 | Patient repositioned and oral care given. Pulse slow and irregular, even unlabored breathing. B. Hardy, RN | |
| 1030 | Vital signs blood pressure 112/78, respirations 14, pulse 66, temperature 100.3. B. Hardy, RN | |
| 1130 | Patient repositioned and oral care given. Duoderm remains in place on coccyx (continued) B. Hardy, RN | |
| 1/1/96 1130 |
(continued) Family in to visit. Patient without pain. Morphine sulfate given every 4 hours as scheduled. Comfort measures provided. No oral intake. B. Hardy, RN | |
| 1400 | Patient given comfort cares. Rigid movements with
extremities. B. Hardy, RN Intervention - provided medication injections, comfort cares. Response - patient remains unresponsive to stimuli, eyes open, staring. Plan - continue comfort measures. B. Hardy, RN | |
| 1500 - 2300 | Behavior - patient unresponsive except to painful stimuli: groans as injections given. Patient often groaned when turned for peri mouth care or during shots. Intervention - gave morphine sulfate as scheduled and prn when patient groaning. Patient turned every 2 hours, comfort care given. Response - patient responded as described above, eyes open staring. Plan - comfort measures. L. Long, RN | |
| 1600 | Free text, medication note: patient groaning, twitching. Medicated with morphine sulfate 5 mg intramuscularly with slightly less twitching observed 30 minutes after morphine sulfate. L.Long, RN | |
| 1730 | Free text: medication note: patient groaning when turned for peri care (continued) L. Long, RN | |
| 1/1/96 1730 NSG |
(continued) and repositioning. Patient medicated with morphine sulfate 5 mg intramuscular. Half hour later no change noted; patient still moans when interventions given. Vital signs: blood pressure 135/75, pulse 84, respirations 12, temperature 98.6. L.Long, RN | |
| 2245 NSG |
Free text: patient appears to be in pain; groaning: patient medicated with morphine sulfate 5 mg intramuscularly. Patient's vital signs: blood pressure 122/77, pulse 77, respirations 12, temperature 98.6. L. Long, RN | |
| 2300 | Free text: doctor notified that morphine sulfate still results in no relief of patient's groaning and moaning. Telephone order for morphine sulfate 5 mg now received. Patient medicated; results pending next shift. L. Long, RN | |
| 1/02/96 11 - 7 |
Night shift free text note: Patient rested quietly. Some groaning noted several minutes prior to 0330 am morphine sulfate intramuscular medication. Wakeful most of the shift. Vital signs stable. Respiratory rate 12 to 16. Pulse 60's to 70's. Afebrile. Blood pressure stable. Turned every 2 hours. No skin breakdown noted. Hands and fingers are bluish in color although skin is warm and dry. Patient is not verbally responsive. Bed bath provided at 0530 comfort measures (skin care, mouth care, etc) provided as needed throughout the shift. L. Wilson, RN | |
| 0800 | Medication entry - oral medications withheld because of unresponsiveness | |
| 0930 | Medication entry - morphine sulfate 5 mg intramuscularly. Patient moaning at this time with eyes open and staring. S. Hansen, RN | |
| 1230 | Medication entry - morphine sulfate 5 mg intramuscularly. Patient moaning at this time. Behavior - patient wakeful, staring into space. Does not respond to verbal stimuli or painful stimuli. When mouth care given patient will suck on swab spontaneously. (over) (continued) (S. Hansen, RN) | |
| 1/02/96 | (continued) Patient on occasion also moving right arm slightly and aimlessly. Intervention - patient turned every 2 hours voided twice. Urine concentrated. Diaper changed. Patient perineum without breakdown. Duoderm to coccyx in place. Mouth clear of mucous - mouth care given frequently. Respirations 12 to 16. Temperature 99.3 at 1030, Temperature 99.8 at 1430. Heart rate 76 to 80 and irregular. Color bluish. Lungs clear, breath sounds decreased. Response - no verbal response, no response to painful stimuli. Some spontaneous moaning. Plan - maintain patient=s comfort by providing change of position every 2 hours, oral care, medications as ordered intramuscularly. S. Hansen, RN. | |
| 1530 | Medication entry: Morphine intramuscular withheld.
Respirations 6 to 10 per minute. Heart rate 67 and irregular. Blood
pressure 138/72. S. Hansen, RN Addendum- patient appears comfortable without moaning. S. Hansen, RN | |
| 1630 | Patient with eyes open, staring, jerking all extremities, moaning. 5 mg morphine sulfate PRN given intramuscularly. Patient turned and positioned. Oral care given. B. Hardy, RN | |
| 1/02/96
1830 |
Medication entry - morphine sulfate IM 5 mg given per
doctor=s
orders. Patient remains unresponsive, staring, cool cloth positioned over
eyes to prevent drying. B. Hardy, RN
Behavior - patient remains with eyes open and starring when cool cloth removed. Fingers cyanotic. Heart rate irregular and strong. No oral fluids taken. Patient clamps teeth on swab, refusing to open mouth. Patient repositioned every 2 hours and oral care given. Intervention - provided medications and comfort measures. Response - patient remains with eyes open and staring. Rigid extremities. Plan - continue to provide comfort measures. B. Hardy, RN | |
| 1/03/96 11 - 7 |
Free text: patient monitored closely throughout the night. Routine morphine sulfate held times 3 due to decreased respirations 5 to 8, slight twitching noted for short period twice. Extremities warm times 4. Fingers cyanotic early in shift, much improved through the night. No mottling observed. Patient turned every 2 hours. Vital signs every 4 hours. Cool, wet cloth to eyes for comfort - otherwise eyes open and staring. Does not respond to when spoken to - no tracking. Oral care done. Patient motioned to mouth this morning, few sips water taken. T. Scholl, RN | |
| 7 - 3 | Behavior - patient was unresponsive for this shift, staring vacantly, at times groaning, at times twitching. Intervention - offer comfort care: mouth and peri care, turning every 2 hours, medications as ordered. Response - patient has had no change in condition this shift; without response during cares or when family visited. Plan: Comfort cares. L. Long, RN | |
| 1/03/96 1530 |
Free text: 5 mg morphine sulfate intramuscularly given per scheduled dose by 2 pm. Patient staring without blinking. Patient positioned and oral care given. B. Hardy, RN | |
| 1740 | Patient repositioned, oral care given. Patient with cyanotic extremities given. Mottling evidences on lower extremities and back. B. Hardy, RN | |
| 1800 | Patient with loud moaning, extremities twitching. Patient positioned and oral care given. B. Hardy, RN | |
| 1830 | Received doctor's order for morphine sulfate 15 mg intramuscularly now and increase morphine sulfate to 10 mg every 3 hours due to patient's agitated state. B. Hardy, RN | |
| 1900 | Patient resting with eyes closed, no twitching, deep respirations noted. B. Hardy, RN | |
| 2000 | Patient with decreased heart rate and deep respirations 10 and with moments of deep sighs and irregularity. No twitching movements. B. Hardy, RN | |
| 2010 | Patient without vital signs present. Listened times 5
minutes for heart rate and respiration. None noted. Supervisor, doctor,
and social worker notified. B. Hardy, RN | |
| 1/03/96 2010 |
Social worker spoke with son of deceased patient. Dr. Weitzel gave order to release body to mortuary. Family declined to view body at hospital, requested mortuary pick up as soon as possible. Mortuary notified. Patient cleansed and belonging bagged for family pickup. No valuables in patient possession. B. Hardy, RN | |
| 2150 | Mortuary picked up patient and signed for pickup. B. Hardy, RN |
Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan