(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 Allergies: No known allergies. 
Verbal order Dr. Weitzel to Lynn Long, RN
Admit to Geropsychiatric unit
Preliminary diagnosis: Provisional Psychosis
Activity: Assist with all activities 
Diet: Regular, mechanical soft
Labs: CBC, Chem 20, RPR, T-7, TSH, Urinalysis with culture and sensitivity if indicated
EKG
AIMES Test
Chest X-ray
Occupational Therapy evaluation and treatment
Physical Therapy evaluation and treatment
Vital signs: Twice a day 
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 at bedtime as needed for constipation
Special Precautions: every 15 minutes check for 24 hours
Betagan 0.5% one drop both eyes twice a day
Surfax one by mouth every day at bedtime
Klonopin 0.5 mg by mouth three times a day
Trazodone 100 mg by mouth every bedtime
Synthroid 0.088 mg one by mouth every day
Baby aspirin one by mouth every day 
Isosorbide 10 mg by mouth twice a day 
Ativan 1 to 2 mg by mouth or intramuscularly every six hours as needed for agitation 
Trazodone 100 mg by mouth once as needed for insomnia after bedtime dose
Zantac 150 mg by mouth every day as needed for abdominal pain
Do Not Resuscitate
Signed Robert Weitzel, M.D. 
Noted Lynn Long, RN 12/6/95 1500

I CERTIFY THAT THIS PATIENT
NEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED Robert Weitzel, M.D.
DATE 12/6/95

12/6/95
MD

Psychiatric evaluation done and dictated. 
Signed Robert Weitzel, M.D.

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

12/7/95
OT

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
MD

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.
Signed Robert Weitzel, M.D

12/7/95
1. Oxygen saturation check, please document here º
2. Serzone 50 mg by mouth twice a day until 12/9/95, then start 100 mg by mouth twice a day.
3. Foam restraint wedge to prevent patient from sliding out of her chair.
Thanks, Robert Weitzel, M.D.
12/7/95
Risperdol 1 mg by mouth every morning, 1700 and bedtime.
Signed Robert Weitzel, M.D.
Noted D. Kley, RN 12/7/95 2125

 RESPIRATORY CARE
PULSE OXIMETRY
OXYGEN SATURATION
DATE 12/7/95 TIME 2145
ON O2 AT 0 L/MIN. OR %
SpO2 (SaO2) ___________%
OFF O2; SpO2 (SaO2) 94%
TECH: ?

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

12/8/95 8 a.m. 
Nystatin swab to mouth and tongue 4 times a day or Nystatin 10 cc swish and swallow 4 times a day until next week 
Serum protein electrophoresis 
Oxygen saturation at bedtime while sleeping 
Glycosalated hemoglobin 
Signed D. Dienhart, M.D. 
Noted L. Wilson, RN 12/8/95
 
 
 

12/8/95 8 a.m. Medicine Consult Note
(asked to see by Dr. Weitzel)
Impression: 
1. Severe dementia / confusion
2. History of Cerebral Vascular Accident - January 95
3. History ischemic heart disease with angina
4. Hypothyroidism, status-post thyroidectomy
5. Status-post multiple falls 
6. Cardiomegaly 
7. Status-post hysterectomy
8. Status-post nephrolithiasis 
9. Probable oral thrush 
10. Large hiatal hernia - history gastroesophageal reflux disease 
11. Decreased albumin, increased globulin
12. Question decreased oxygen saturation on admit
13. History of increased glucose 9/95
Recommendation:
1. Treat oral thrush with Nystatin
2. Serum protein electrophoresis screen for monoclonal (unreadable word)
Elderly female increased dementia since January 1995 CVA. Apparently living in retirement center in (indecipherable).
Worsened over past three weeks. Certainly component of dementia may be due to multiple infarctions. Cardiac failure appears to be compensated. Question intermittent decreased oxygen saturation. 
Laboratory: thyroid function, decreased albumin, increased globulin noted. 
Chest x-ray: cardiomegaly, hiatal hernia, no infiltrate. 
EKG: sinus rhythm, question of ectopic focus. 
Rest per dictation. 
Thanks, D. Dienhart, M.D.

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
MD

Much calmer today after starting Risperdol, lethargic at times. Very demented. Vital signs stable, afebrile. Assessment - Psychotic depression. Plan - taper Klonopin, continue other medications.
Signed Robert Weitzel, M.D.
Addendum B three old CT scan results January - September 1995 have been obtained - left frontal and occipital encephalomalacia consistent with old infarction. 
Signed Robert Weitzel, M.D.

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

12/9/95
MD

Very dysphoric, continues to exhibit echolalic perseveration. Affect labile. No combativeness. Highly agitated. Assessment - very psychotic. Plan - Increase Risperdol and Trazodone. 
Signed Robert Weitzel, M.D.

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

12/10/95
MD

Mild fever has disappeared. Much less agitation. Quite demented. Assessment - Stable. Plan - continue current medications.

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
MD

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. 
Signed Robert Weitzel, M.D.

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
1930

(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

2100

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)

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

12/12/95

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. 
Robert Weitzel, M.D.

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

12/13/95
MD

Answered one question intelligibly today: "How are you?" - "I feel bad," then refused to answer. Eating and taking fluids now. Vital signs stable, afebrile. Appears to be in some pain. Remains fairly profoundly demented. Assessment - Major depressive disorder with psychotic features. Plan - continue Klonopin taper, and Serzone and Risperdol. Morphine sulfate for pain .
Signed Robert Weitzel, M.D.

12/13/95
OT

Patient was unable to be assessed today secondary to medication. J.V.? COTA

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

12/14/95
MD

Has made a miraculous recovery; ambulated yesterday, taking food well. Vital signs stable, afebrile. Assessment - Doing much better. Remains demented. Plan - continue current treatment. 
Signed Robert Weitzel, M.D.

12/14/95
RD

Weekly nutrition summary: oral intake very poor, must have assist with feeding at all meals, generally 5-30% of meals eaten. Goal for patient - 30% of all meals to be eaten. Weight decreased to 121.8 lbs (decreased approximately 1lb.) 12/9/95 albumin 3.3 decreased total protein 6.5 Glycolated hemoglobin - 5.8 - within normal limits. Pureed diet order appropriate, will make changes on breakfast meal to increase intake. Adding (?) to all meals to encourage increased oral intake of kilocalories/ protein. Following. M. Fagg, RDCD

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, CAN

12/15/95
0630

Free text: patient slept well, turned every two hours during shift. No problems noted at this time. Ables, CNA. 

12/15/95

MD

Responded to me this morning fairly appropriately. Blood pressure a little labile. Dysphoric. Often lethargic. Mildly febrile yesterday, now okay. Assessment - Major Depressive Disorder with psychotic features, improved. Better intake. Plan - continue treatment, probably won't need "hospice."
Signed Robert Weitzel, M.D.

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

12/16/95
MD

Continues to do well, despite earlier moribund state. Vital signs stable, afebrile. Demented, but much more responsive. Eating/sleeping well. Assessment - improved. Plan - continue current care.
Signed Robert Weitzel, M.D.

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

12/17/95
MD

Stable, doing well. Vital signs stable, afebrile. Assessment - Stable. Plan - continue current care.
Signed Robert Weitzel, M.D.

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

24 hour check 12/18/95 0115 T. Scholl, 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

12/18/95
MD

I spoke extensively with her son this morning to inform him of the changes in her status. We will have to wait and see how she does in future before making plans for placement. Although quite demented, she is self-feeding, walking, and responding in a semi- normal manner to questions. Vital signs stable, afebrile. Assessment - much improved. Plan - Decrease Risperdol. Signed Robert Weitzel, M.D.

12/18/95 ?
Recreation Therapy

Recreation weekly -patient has made a lot of progress this week. Earlier she wasn=t able to attend group due to confusion and calling out. She has woke up able to follow simple commands. Will continue encouragement and (R.O.?) with her encouraging interaction. B. Foulger, IRT

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

12/19/95
MD

Doing well, although quite demented. Vital signs stable, afebrile. Fed herself tonight. Assessment - stable. Plan - continue current care. Signed Robert Weitzel, M.D.

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

12/20/95
MD

Continues with slow improvement. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care. 
Signed Robert Weitzel, M.D.

(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

12/21/95
MD

Sleeping well. Vital signs stable, afebrile. Doing quite well: feeding herself, much more alert, better energy, answers responsively, occasionally labile mood with tears. Remains demented. Assessment - improved. Plan - continue current medical treatment. 
Signed Robert Weitzel, M.D.

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

12/22/95
FT

Social Work Note: Met with patient=s son and daughter-in-law. Discussed patient's progress. Facilitated discharge planning. Family is considering various nursing home facilities which include Holladay Care Center, St. Joseph=s Villa and possibly Godfrey's in Brigham City. Encouraged son to discuss those options with siblings to determine which facility family deems most appropriate. Provided supportive counseling. K. Steglich, CSW

12/22/95
MD

Remains demented. Stable overall. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.

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.

12/23/95
MD

I was called regarding patient being somewhat unresponsive with nystagmus yesterday, but now she is doing well, overall. Mild fever (versus borderline normal), vital signs stable. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.

(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

12/24/95
Nursing

Weekly nursing note: patient has at times fed self and responded to questions appropriately this week, but at other times has been unresponsive, unable to (continued) L. Long, RN

12/24/95
Nursing

(continued) feed self, staring with flat affect or sitting with eyes closed, at times refusing medications or food by tightly clamping lips together. Continue current care. L. Long, RN

12/24/95
MD

Quite lethargic. Vital signs stable, afebrile. No assaultive behavior. Sleeping well. Eating fairly well, overall. Has few bowel movements. Assessment - Stable. Plan - Prune juice. 
Signed Robert Weitzel, M.D.

(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

12/25/95
MD

Remains less responsive than one week ago, after the initial improvement. No agitation. Slept well. Vital signs stable, afebrile. Assessment - stable. Plan - continue current therapy.
Signed Robert Weitzel, M.D.
Addendum - patient seems to be in pain, once woken. Will try some low dose Morphine sulfate at frequent intervals, to see if this is the problem.
Signed Robert Weitzel, M.D.

12/25/95 0930 
Telephone order Dr. Weitzel / L. Long, RN
Morphine sulfate 2 mg intramuscularly now.
Signed Robert Weitzel, M.D. 
Noted L. Long, RN 12/25/95 0930

12/25/95 1130
Telephone order Dr. Weitzel / L. Long, RN
Morphine sulfate 2 mg now 
Signed Robert Weitzel, M.D.
Noted L. Long, RN 12/25/95 1130

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 0605 
Telephone Order: Dr. Dienhart / T. Scholl, RN
IV: D5 
Ativan IV Titrate 1 to 3 mg over 5 minutes until seizure stops. 
12/26/96 0620 Telephone order Dr. Dienhart / T. Sholes, RN
Give additional 1 mg Ativan IV now 
Signed D. Dienhart, M.D. 
Noted T. Scholl, RN 12/26/95 

12/26/95 7 a.m. 
Oxygen saturation/ oxygen at 2 liters per nasal cannula
titrate oxygen saturation to greater than or equal to 90%.
IV D5 2 NS at 70cc per hour with Dilantin infusion
Dilantin 1 gm IV load over 40 minutes in normal saline line then 100 mg IV every 8 hours. 
EKG
Chem-20, CBC
CT scan head now - rule out cerebral bleed.
Dilantin level every morning at 9 am
Blood pressure every 10 minutes during Dilantin infusion
Signed D. Dienhart, M.D. 
Noted 12/26/95 0800 S. Hansen, RN

12/26/95 0650 Medicine Consult Note:
(Asked to see by Dr. Weitzel)
93 year old female admitted 12/20 to Geropsychiatry Unit for increased dementia.
Past medical history significant for past CVA. Called to see for nursing witnessed tonic-clonic seizure - total duration 40-45 minutes, relieved after Ativan 4 mg slow IV. Nurse described right arm and right leg and right facial jerking. 
Note: Risperdol / Serzone / Thyroid
Now apparently post-ictal - during seizure (blood pressure) 160/100, now dosing Dilantin - 104/60
Mouth - decreased gag, (unreadable word) lower denture, no visible bleeding. 
Lungs decreased breath sounds
Abdomen: soft
Neuro: 2 + and roughly equal at biceps and knees. Increased (unknown word) on right. 
Impression: 
Seizure, post-ictal
Right-sided activity
Rule out left event
Recommendation: 
Rule out cerebral vascular accident - new event - with CT scan
Maintain Dilantin 100 mg three times a day for now 
Oxygen as needed 
for EKG and (unknown word) changes.
Signed D. Dienhart, M.D.

12/26/95
0800

0900

Morphine sulfate 2 mg intramuscularly right quadrant - complaint of moaning, appears to be in some discomfort. 

Patient quiet and unresponsive to even deep painful stimuli. All comfort measures continued. Oxygen at 2 liters per nasal cannula, color pink.   S. Hansen, RN

12/26/95
OT

Occupational Therapy Weekly Summary Note: Patient attended occupational therapy group sessions 50% this week. Patient cannot follow one-step commands and requires multiple cues to redirect. Patient continues to make inappropriate comments when in group. J.V.? COTA/L

12/26/95
MD

Yesterday morphine sulfate was tried for comfort care. She had a seizure this morning, was started on Dilantin, looked pretty ill at first, blood pressure decreased; now feeding self again. Assessment - Unstable health status. Plan - continue current medications and treatment.
Signed Robert Weitzel, M.D.

1400

Behavior - patient unresponsive as yet, but appears to be lighter. Not moving in bed but making verbal noises in response to conversation with her. Intervention - comfort measures: turning, changing - incontinent once. Mouth care, and repositioning. Response - no response until 1400 when she appeared to be attempting to respond. Patient has appeared comfortable since receiving Morphine sulfate intramuscularly at 0800. Plan - keep patient comfortable. Attempt to communicate with patient by voice and touch. S. Hansen, RN

1400

Free text. Blood pressure gradually up 108/70 at present. Respirations even and unlabored. Heart rate irregular at 88. S. Hansen, 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, CAN

12/27/95

MD

No evidence pain now - no crying out - does appear quite lethargic. Vital signs stable, afebrile. Assessment - same. Plan - continue to observe. Robert Weitzel, M.D.

 (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

AUTOMATIC DRUG STOP ORDER
Patient: Judith Room 
Drug(s) Exp. Date Last Dose
1. Serzone 100 mg bid po exp - 12/27 
2. 
3.
4.
According to hospital policy orders for these medications 
must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
Noted 12/28/95 0130 T. Scholl, RN

24 hour check 12/28/95 0130 T. Scholl, RN

12/28/95
Dietary

Weight 125 lbs, increased 4 lbs since admission. New labs: albumin 2.7, total protein 5.8. Intake continues to vary greatly. Nursing reports that patient does better with very liquid foods, especially (?) and Healthshakes. Will provide these with each meal and Sustacal (free of charge) three times a day. Will monitor intake, labs and weight. R. Warner Nutritionist

12/28
Rec

Recreation note - for a few days patient was awake attempting to participate . Her medical condition deteriorated so she was unable to participate - will continue working with her. B. Foulger, IRT

12/28/95
MD

I met with her son and daughter-in-law. She appears medically stable at this point. The Dilantin appears to be causing some sedation; the lethargy continues. Vital signs stable, afebrile. Assessment - stable. Plan - continue current care.
Signed Robert Weitzel, M.D.

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

24 hour check 12/29/95 0230 T. Scholl, 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

12/29/95
MD

Has quit feeding self - stares off into space. No further seizure activity. I wish to keep medications to a minimum. Vital signs stable, afebrile. Assessment - Major Depressive Disorder with psychotic features, status post cerebrovascular accident, dementia. Assessment - discontinue Dilantin - we=ll see if we can get her to be responsive again. If she seizes will use intramuscular Ativan.
Signed Robert Weitzel, M.D.

12/29/95
Social Services

Late entry for 12/26/95. Social Work Weekly Summary Report: Patient involved in individual and group at times therapy. Patient participation in group very limited. Patient alert, but disoriented and confused. Patient participates in one-on-one therapy but limited in ability to verbalize feelings, has difficulty tracking. Continue with master treatment plan. K. Steglich, CSW.

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

24 hour check 12/30/95 0600 T. Scholl, 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

12/30/95
MD

Met with son and daughter this evening regarding patient=s condition; she had coffee grounds - vomitus of greater than 200 cc this morning. Stomach is distended, has hyperactive bowel sounds, heart rate quite erratic. Assessment - gastrointestinal bleed. Plan - make sure she's comfortable with routine morphine sulfate .
Signed Robert Weitzel, M.D.

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. SB. 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
11 - 7 

Night shift free text note: Respiratory rate 10-16 per minute. Patient is gazing at light from bathroom when she is awake. She is not verbally responsive. Morphine sulfate 5 mg intramuscularly given at 0230 and 0630 for pain relief. Patient was moaning prior to 0230 dose of medication. Nursing supervisor is aware of patient's condition. L. Wilson, RN

0730

Behavior - patient with eyes opened, no blinking. Not responding to verbal stimuli and tactile stimuli. No output. Patient turned and positioned. Oral care provided. Moist cloth to cover eyes to prevent drying out. Patient closed eyes while cloth in place. Son very concerned about patient's medical condition, wanted to know "when patient would be dying." Staff nurse told son patient's medical status and responses to cares and medications being given. Family member upset that staff nurse would not state patient was dying. Patient condition poor. (continued) B. Hardy, 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

12/31/95
MD

Unresponsive. Melena during the night. Blood pressure fluctuates and is low, generally. Taking no oral fluids or nourishment, is receiving oral care. I spoke to her son per telephone this morning, and am meeting with son and daughter soon. Afebrile. Assessment - gastrointestinal bleed, low blood pressure, unresponsive. Plan - continue comfort care. Robert Weitzel, M.D.

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

1/1/96
MD

Generally unresponsive. Blood pressure remains pretty good. Seems in some discomfort. Afebrile. Assessment - Quite ill. Plan - Increase morphine sulfate dose schedule (decrease interval). PRN now. Continue all comfort care. Robert Weitzel MD

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

1/02/96
Nursing

Weekly Nursing Advocate note: Patient is currentlyPatient's medical status has rapidly and profoundly deteriorated this week. She has experienced a seizure and multiple episodes of vomiting coffee grounds material. She is no longer verbally responsive. The care plan has been altered to reflect the need to support patient and family through a positive death and dying process.  Patient is currently receiving morphine sulfate intramuscularly every 3 hours for comfort. L. Wilson, RN

1/02/96
MD

Stable vital signs, actually. Unresponsive, overall, does open eyes at times. Afebrile. Assessment - quite ill. Plan - continue comfort care. Robert Weitzel, M.D.

1/02/96
OT

Patient continues to require maximum assist to arouse: patient is unable to participate in sessions secondary to decreased arousal. J.V. ? COTA

0800