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Judith Larsen
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Brief History and Hospital Course
This 93 year old widowed white female had previously become severely agitated and depressed, and could not speak intelligibly. She had suffered a profound stroke in August, four months PTA, and exhibited what appeared to be severe multi-infarct dementia with multiple previous CVA’s seen on CT scan. Holladay Health Care Center could no longer contain her agitation, yelling, and continual falls with head lacerations. She had previous medical history significant for angina and ischemic heart disease. Medications on admit included Isordil, Synthroid, Zantac, and routine Xanax, Zoloft, and trazodone.
Her Xanax was stopped and the patient begun on a slow benzodiazepine taper, using Klonopin. Zoloft was discontinued in favor of Serzone. Risperdal was started, and slowly increased, while trazodone was continued. On the fifth hospital day 12/11 she appeared seriously ill, with poor fluid intake, but an IV was proscribed by her Medical Treatment Plan. Her son at this point said he wanted to "let her go."
On the seventh hospital day 12/13 she appeared to be in distress or pain, and morphine prn was ordered, but never used, and this prn was discontinued on 12/19. Instead she improved markedly, and though she remained profoundly demented, her energy, mood and self-care improved steadily until about the 24th, her eighteenth hospital day, but from that point she deteriorated, with less agitation but progressively increasing dysfunction, including poor oral intake. On Christmas Day small 2 mg. doses of morphine were tried due to the patient appearing to be in pain; this did seem to help her but she did poorly again when it wore off.
On the 26th the patient had an apparent seizure and the internist started an IV and Dilantin loading, despite the prohibition in her Medical Treatment Plan against IV’s. This IV was discontinued by the psychiatrist. The head nurse noted pain and discomfort, and a now order of morphine 2 mg. IM helped; later that day she fed herself. On 12/30, her 24th hospital day, she had "coffee grounds emesis" – copious hematochezia, and her HCT dropped from 40 to 30 immediately. On the next day she had melena, was hypotensive, and was unresponsive. The family was informed of the poor prognosis with no IV, and on 12/30 decided she would be best served by not intervening. All previous medications were discontinued. Morphine was gradually increased from 5 mg. q4hrs to q3hrs, and then 10 mg. q3hrs, with additional now and prn orders for acute breakthrough discomfort and pain. Unfortunately, during the night of the 2nd through the 3rd, a nurse completely held all scheduled doses of analgesic secondary to her fear of patient respiratory depression, and when the physician arrived in the morning the patient was groaning in pain, twitching, and repeatedly "moaning loudly" still at 6:00 PM that evening. Because of the nurse allowing the pain to go completely untreated it was very difficult to regain control, and the physician was in touch with the unit throughout the day by telephone, ordering repeated higher doses of morphine in addition to her scheduled doses, all in response to nurse reports of symptoms. One 15 mg., one 25 mg., and two 30 mg. doses were needed (besides scheduled doses) to get pain and suffering curbed. The patient died at 8:10 PM, her family at her side.
MEDICAL TREATMENT PLAN
I, Dr. Gregory Stevens, certify that I am the attending physician for Judith Larsen of ______, who is presently under my care this
day of , 19.
The declarant, the above named patient, is currently suffering from the
following injury, disease or illness:
I certify that I have explained to the declarant to the extent he/she is able to understand, and to the available person(s) acting as proxy, the reasonably available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:
directed by the declarant: or
X that the declarant has a physical or mental condition which renders him/her unable to give personal directions for care ad treatment and that the care and treatment alternatives directed below are in my opinion, and in the opinion of the declarant’s proxy, what the declarant would probably decide if able to give current directions concerning his/her care and treatment.
Date: September 19, 1985 (Signed)
Greg Stevens
Attending Physician
The following care and treatment or withholding of treatment is directed with respect to the declarant:
No CPR. No IVs for nutrition, hydration, medication. No feeding tubes. No
mechanical respiratory assistance. No electric shock for defibrillation. No
treatment for cancer. Oxygen and oral medication may be given for relief of pain
and for comfort.
Son
(Signed) Merlin N. Larsen
Relationship to declarant Signature of declarant or authorized agent Agent signing for declarant.
Address of signer, including city, county and state of residence
LIVING WILL
1) On this 25th day of May, 1995, I Judith V. Larsen, being of sound mind, hereby willfully and voluntarily make known my desire that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive. I understand that the term "life-sustaining procedure," as defined by law i) means any medical procedure or intervention which, when applied to a person who has a terminal condition would, in the judgement of the attending physician, serve only to prolong the dying process, ii) does not mean medication, sustenance, or medical procedures for providing comfort care or for alleviating pain, unless I so specify below.
2) I declare that if at any time I should have an injury, disease or illness, which is certified in writing to be a terminal condition or persistent vegetative state by two physicians who have personally examined me, and in the opinion of those physicians the application of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or withdrawn and my death be permitted to occur naturally.
3) I expressly intend this directive to be a final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from this refusal, which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other providers of medical services.
4) I understand that the term "life-sustaining procedure" includes
artificial nutrition and hydration and any other procedures that I specify below
to be considered life-sustaining but does not include the administration of
medication r the performance of any medical procedure which is intended to
provide comfort care or to alleviate pain: If my condition is certified to be
terminal as in paragraph 2, I request that sustenance (meaning nutrition and
hydration and respiration) be terminated or withheld. Medication to relieve pain
may be given if obviously needed.
5) I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even though these directions may conflict with the above-written directive that life-sustaining procedures be withheld or withdrawn.
6) I understand the full import of this directive and declare that I am emotionally and mentally competent to make this directive.
(Signed) Judith V. Larsen
Declarant Signature
Salt Lake City, Utah
City, County, State of Residence
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(12/06/95) Med Note |
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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 |
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12/6/95 Allergies: No known
allergies. |
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I CERTIFY THAT THIS PATIENT |
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12/6/95 |
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Psychiatric evaluation done and
dictated. |
12/6/95 1700
Oxygen at 2 liters per nasal cannula to keep saturations above 90%
Telephone order Dr. Weitzel/ B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted B. Hardy, RN 1700 12/6/95
DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Larsen, Judith
Robert Weitzel MD
Admit: 12/06/95
CHIEF COMPLAINT
The patient’s family complains that she has been quite agitated, screaming, shouting nonsensical syllables and is demented.
IDENTIFYING INFORMATION
The patient is a 93 year-old widowed white female, who had been living in the Holladay Health Care Center.
HISTORY
The patient reportedly had a stroke in August and was unable to speak or swallow but apparently after sustaining a head laceration after a fall out of bed she was once again able to speak and swallow. Lately she has become very upset and agitated and has had poor intake and has needed assistance with all of her ADLs and has had quite bizarre behavior. She is crying, shouting when awake, sleeping most of the time and is fairly unresponsive. She fights against restraints. The patient has lost continence of bowel and bladder.
PAST PSYCHIATRIC HISTORY
The patient was hospitalized in the late 50s and had ECT for depression. There is no history of her being on antidepressants recently.
PAST MEDICAL HISTORY
As noted above she had CVA apparently 8/25/95, there are multiple old infarcts on CT scan.
MEDICATIONS: Currently include Synthroid 0.088 mg. q. day, Isordil 10 mg b.i.d., one baby aspirin per day, Trazodone one q. h.s., Xanax 0.5 mg p.o. t.i.d. and Betagan 0.5% one drop each eye b.i.d. as well as Zantac 150 mg q. day. She had had a history of several falls from bed in the last year and in 1985 through 1990 she had bilateral cataract surgery and apparently in the 1930s she may have had a thyroid goiter. In 1954 she had a hysterectomy.
Continued….
Judith Larsen
Page 2…. PE
Robert A. Weitzel, M.D.
SOCIAL HISTORY
The patient has been living in the Holladay Health Care Center. She has supportive children. Apparently she believes her son to be her husband, who has died. She dropped out of high school and got married at age 16. She has been a homemaker and seamstress. She is a member of the L.D.S. Church. She does not smoke or drink.
FAMILY HISTORY
Negative for psychiatric. There is some thyroid disease in the family.
PATIENT STRENGTHS
Support of family.
PATIENT LIMITATIONS
Dementia and nonresponsive at the time of examination.
MENTAL STATUS EXAMINATION
The patient is an elderly female, who appears undistressed. Speech exhibits echolalia, mood is very dysphoric, affect is congruent, somewhat labile. The thought process is very loose. Thought content is difficult to ascertain. She is unresponsive. She apparently hears and sees but it is difficult to ascertain to what level. IQ seems very low. Calculations were not tested. Memory is not testable. Abstractions not testable. Fund of knowledge is not testable. Insight is poor. Judgment is poor.
DIAGNOSIS
Axis I: Major depression with psychotic features. Rule out organic brain syndrome.
Axis II: Defer.
Axis III: CVA, hypothyroidism.
Axis IV: Three.
Axis V: Fifteen.
DISCUSSION & RECOMMENDATIONS
We will get full medical work-up and probably start Serzone and Respirdol.
Continued…
Judith Larsen
Page 3… PE
Robert Weitzel MD
ESTIMATED LENGTH OF HOSPITALIZATION
Two weeks.
DISCHARGE CRITERIA
Decreased psychoses and depression.
DISCHARGE PLAN
Back to Holladay Health Care Center.
(Signed) Robert A. Weitzel, M.D.
RAW/lw
D: 12/07/95 21:04
T: 12/08/95 9:49
Job #00096
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12/6/95 |
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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 |
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2300 |
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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 |
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24 hour chart check 12/7/95 0330 T. Scholl, RN
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12/7/95 |
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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 |
12/7/95
Straight catheterization for urinalysis
Telephone order - Dr. Weitzel/E.Cozzins,RN
Signed Robert Weitzel, M.D.
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12/7/95 |
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Attempt made
to establish communication and have patient follow one-step command;
patient unable to complete task. Patient demonstrates decreased cognition
status. Will attempt to complete evaluation
tomorrow. J.V.? COTA/L |
12/7/95 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
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12/7/95 |
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Patient
continues to moan and cry; quite dysphoric, will not respond to questions.
Assessment - Major Depressive Disorder with psychotic features. Plan -
Serzone and Risperdol with the Klonopin. |
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12/7/95
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RESPIRATORY CARE |
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12/7/95 |
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Free text -
patient acting painful by pulling faces. Medicated with Tylenol 2
tablets for pain. (?) LPN |
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1730 |
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Tylenol effective (?)LPN |
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2030 |
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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 |
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2215 |
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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 |
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12/7/95 |
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(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 |
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24 hour chart check 12/8/95 0345 T. Scholl, RN
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12/8/95 |
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Free text: patient slept all
shift. Patient turned three times. Incontinent once. Very restful night.
Ables, CNA |
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12/8/95 8 a.m.
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DAVIS HOSPITAL & MEDICAL
CENTER
REPORT OF
CONSULTATION
PATIENT: Larsen, Judith
DATE OF CONSULTATION: 12/08/95
ATTENDING PHYSICIAN: Robert A. Weitzel, M.D.
CONSULTING PHYSICIAN: David Dienhart, M.D.
REASON FOR CONSULTATION
Admission to the psychiatric unit for worsened dementia/provisional psychoses, evaluation of medical problems.
HISTORY
This is a 93 year-old female who by history suffered a cerebrovascular accident in January of 1995. Since that time she has been less communicative. By history she was living in a retirement center as late as July 1995. She has recently been residing in the Holladay Health Care Center. Since late August 1995 she has had essentially no speech, she has been restrained in bed, she has fallen out of bed and received head lacerations.
PAST MEDICAL HISTORY
Remarkable for cerebrovascular accidents, diagnosis of ischemic heart disease, history of angina, hypothyroidism, status post thyroidectomy, history of nephrolithiasis and history of hiatal hernia with gastroesophageal reflux disease.
On examination today the patient does not communicate. She does not verbally explain of any pain.
MEDICATIONS: Betagen 0.5% one drop each eye b.i.d., Surfak one p.o. q. day h.s., Clonopin 0.5 mg p.o. t.i.d., Trazodone 100 mg p.o. q. h.s. Synthroid 0.88 mg one p.o. q. day, baby aspirin one p.o. q. day. Isosorbide 10 mg p.o. b.i.d. Ativan 1-2 mg p.o. IM q. 6 hours p.r.n. agitation. Zantac 150 mg p.o. daily p.r.n. abdominal pain.
Continued…
REPORT OF CONSULTATION
Judith Larsen
Page 2 … CO
David Dienhart, M.D.
MEDICAL: Past history of cerebrovascular accident in January of 1995. Note: CT scans of the brain on 8/26/95 and 9/14/95 showing no evidence of acute cerebrovascular injury. There is left frontal and occipital encephalomalacia consistent with old areas of infarction, which are unchanged on the 9/14/95 when compared to the 8/26/90. On examination there is diffuse white matter changes and small vessel disease. These areas of encephalomalacia are felt to be large areas involving the left frontal and occipital lobes.
There is the past medical history of ischemic heart disease with angina, undefined in the medical record. History of hypothyroidism, status post thyroidectomy with unclear reason for thyroidectomy. History of multiple falls in the last year. History of nephrolithiasis. Elevated glucose on history and physical of 9/14/95 by Dr. Stevens.
ALLERGIES: HISTORY OF ALLERGY TO VALIUM AS NOTED IN THE OLD CHART.
SOCIAL HISTORY
Per past dictation the patient has no history of alcohol or tobacco use.
PHYSICAL EXAMINATION
GENERAL: The patient is a 93 year-old thin female who is supine at rest in bed. The patient is observed to ambulate with a very small gait, shuffle, with assistance.
VITAL SIGNS: Respirations are 16-20 per minute. Heart rate is about 70 per minute. Temperature is 97 degrees. Blood pressure is 107/60.
HEENT: The left eye shows evidence of a left iridectomy and is nonreactive. The right pupil is approximately 2 mm and minimally reactive. The conjunctiva are pink. Tympanic membranes are clear of cerumen. The throat is clear. There are upper dentures. The lower teeth are only in fair repair. The tongue is red and dry suggesting early oral thrush.
NECK: Supple. There is no adenopathy.
AXILLAR: No adenopathy.
BREASTS: Pendulous, showing no evidence of mass.
CARDIAC: Regular.
Continued….
REPORT OF CONSULTATION
Judith Larsen
Page 3 … CO
David Dienhart, M.D.
LUNGS: There are poor breath excursions and poor cooperation without rales or wheezes appreciated.
ABDOMEN: Soft, nontender. There is no hepatomegaly.
EXTREMITIES: No edema.
NEUROLOGIC: There are 2+ biceps, ¼+ knee jerks bilaterally.
There is no Babinski.
Chest x-ray on admission shows cardiomegaly, probably large hiatal hernia. There is no evidence of infiltrate. EKG from 12/6/95 shows a probable sinus rhythm at 79 beats per minute. There is slightly unusual P wave axis suggesting a possible extopic atrial rhythm. There is occasional premature ventricular supraventricular complexes. There is a left anterior vesicular block. Poor R wave progression V1 through V4, suggesting old septal infarction. The R wave is low amplitude V4 through V6.
LABORATORY DATA On 12/6/95 sodium 136, potassium 4.3, chloride 103, CO2 30, anion gap 3, glucose 163, BUN 18, creatinine 0.8, calcium 9.8, uric acid 4.7, cholesterol 197, triglycerides 119, total protein 7.4, albumin 3.3, globulins 4.1. total bilirubin 0.6, alkaline phosphatase 58.GGT 13, ALT 11, AST 23, LDH 188. Phosphorous 3.1, magnesium 1.9. Iron 25. TSH 3.1. T3 29.6, T4 8.6, T7 2.55. WBCs 5,100, hemoglobin 13.7 hematocrit 41.2. Platelet count 274,000. RPR is nonreactive. Urinalysis color yellow, appearance clear, specific Gravity 1.015, pH 5.0, WBCs 1-2, bacteria 2+
IMPRESSION
Continued
Judith L.
Page 4 … CO
David Dienhart, M.D.
RECOMMENDATIONS
Thank you for asking me to evaluate this patient.
(Signed) David Dienhart, M.D.
DD/lw
D: 12/08/95 08:14
T: 12/08/95 13:37
Job #00140
REPORT OF CONSULATION
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0700 - 1500 |
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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.
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12/8/95 |
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Much calmer today after starting
Risperdol, lethargic at times. Very demented. Vital signs stable,
afebrile. Assessment -
Psychotic depression. Plan - taper Klonopin,
continue other medications. |
12/8/95
Klonopin: Decrease to 0.5 mg by mouth twice a
day, today through 12/12/95, then on 12/13/95 begin Klonopin 0.25 mg by mouth
twice a day for one week.
Thanks, Robert Weitzel, M.D.
Noted L. Wilson, RN 12/8/95 2000
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12/8/95 |
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Problem: altered thought process. |
24 hour chart check 12/9/95 0430 T. Scholl, RN
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12/9/95 |
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PRN Ativan given for agitation at 0300. Effective for approximately 1 2 hours. T. Scholl, RN |
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0645 |
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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 |
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(7a – 3p) |
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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 |
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12/9/95 |
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Altered thought process |
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12/9/95 |
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Very
dysphoric, continues to exhibit echolalic perseveration.
Affect labile. No combativeness. Highly
agitated. Assessment - very psychotic. Plan - Increase Risperdol
and Trazodone. |
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12/9/95
1. Risperdol 1 mg by mouth every morning, 2 mg by
mouth at 1700 2 mg by mouth every bedtime.
2. Trazodone 150 mg by mouth every bedtime
Thanks, Robert Weitzel, M.D.
12/9/95
Ativan 2 mg intramuscularly now.
Thanks, Robert Weitzel, M.D.
Noted L. Wilson, RN 12/9/95 2200
24 hour check L. Wilson, RN 12/10/95 2400
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12/10/95 |
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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 |
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12/10/95 |
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Mild fever has disappeared. Much
less agitation. Quite demented. Assessment - Stable. Plan - continue
current medications. |
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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 |
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12/10/95 |
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Problem: altered thought process |
24 hour check L. Wilson, RN 12/11/95 2400
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12/11/95 |
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Patient rested quietly thorughout
shift. Respirations slow, deep and regular. Not roused by every 15 minute
nursing checks. L. Wilson, RN |
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(7a – 3p) |
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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 |
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12/11/95 |
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Patient is
taking fluids very poorly. Oxygen saturation was 77. Medical Treatment
Plan proscribes IV. No
intelligible responses noted. I
spoke with her son Merlin and explained the situation. He reiterates a
desire to follow her wishes and let her go.
Assessment - Stable. Plan - Continue current medications. |
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12/11/95
1. Risperdol 1 mg by mouth every morning, every
1700, and every bedtime.
2. Discontinue Nystatin
Thanks, Robert Weitzel, M.D.
Noted 12/11/95 at 1200 S. Hansen, RN
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12/11/95 |
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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 |
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1730 |
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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 |
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12/11/95 |
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(continued) Patient's family
member called and requested information on patient's status. Family continues to not want IVs, feeding tubes, etc. as per Living
Will. Oxygen okayed. Family relieved to hear patient is not
screaming out or agitated currently. Patient given oral care and
repositioned, patient without labored breathing. Oxygen continues at 3
liters per nasal cannula. Patient responds only to tactile touch.
Circulation remains less than 3 second capillary refills. Heart rate
regular, respirations, even. B. Hardy, RN |
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2100 |
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Patient positioned in upright
position, staff attempted to arouse for evening medications. Patient not
responsive to tactile touching. Patient with normal S1S2 heart rate.
Respirations 22, temperature 99.4, blood pressure 110/80. Patient shows no
signs of distress. Wet diaper once. Patient was not able to oral
medications. Patient given oral care and repositioned. Intervention -
provide cares, repositioning. B. Hardy RN (continued) |
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12/11/95 |
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(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 |
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24 hour check L. Wilson, RN 12/12/95 2400
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12/12/95 |
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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 |
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12/12/95 |
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Putting out some urine, despite
poor fluid intake. Vital signs stable, afebrile. Very
demented. Risperdol seems to be controlling most of her agitation.
Assessment - stable. Plan - continue current care. |
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7 - 3 |
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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 |
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12/12/95 |
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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 |
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24 hour check L. Wilson, RN 12/13/95 2400
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12/13/95 |
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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 |
RESPIRATORY CARE
PULSE OXIMETERY
OXYGEN SATURATION
DATE 12/12/95
TIME 1000
ON O2 AT 4 L/MIN. OR %
SpO2 (SaO2) ___90%
OFF O2; SpO2 (SaO2) 81%
TECH: ?
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1400 |
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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. |
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