Lydia Smith
Brief History and Hospital Course
This 90 year old widowed white female had a two week history of severe agitation, was highly combative, restlessly wandering, spitting and scratching, and appeared deeply dysphoric, all this after a severe parietal stroke four weeks prior to admission, with probable thalamic component, superimposed on long-standing dementia. She had been at Rocky Mountain Care Center before the stroke but was too aggressive for return. She had medical history of unstable angina, atrial fibrillation, HTN, CHF, and myocardial infarction, and had recently received Darvocet for chest pain in the months before admission. Other medications included Lasix, KCl, Lanoxin, Normodyne, Vasotec, and Haldol 0.5 mg. tid, with another 1 to 2 mgs. prn, and Serzone 100 mg. bid.
She had a history of 30 lb. weight loss in the recent months.
On admission 12/20/95 she continued on prior medication but Risperdal 0.5 mg. tid was substituted for Haldol, with Haldol the default antipsychotic, given IM, when the patient frequently refused oral medication. Cipro was given for a UTI. Depakene was added, then trazodone, and then psychotropics were gradually increased in response to symptoms. Finally, clonidine patch was added to try to control continued serious aggression and agitation. Despite all of this, symptoms continued, with the patient "…very agitated...striking at staff…" on 1/5, and "…attempting to remove diaper..." and "ambulating, (but) feeding poorly…" on 1/6. The patient repeatedly refused oral medication, food, and fluid throughout the hospitalization.
On 1/7, her nineteenth hospital day, she was weak, not taking fluids or nourishment, and her urine output dropped to zero. Family discussion was held, and the family directed that all interventions be withheld. At this point the patient was understood by the physician to be terminal. All previous medications were stopped. Morphine 5 mg. IM q3hr was started, and this was increased to 10 mg. q3hr the next day, 1/8, when she died. Her weight, 116 on admission, was 108 at death.
DAVIS HOSPITAL AND MEDICAL CENTER GEROPSYCHIATRIC UNIT
1600 WEST ANTELOPE DRIVE
LAYTON, UTAH 84041
MEDICAL TREATMENT PLAN
Patient’s name:_Smith, Lydia__________________Date: 12/20/95________________
I, (signed) Robert Weitzel, M.D. certify that I am the attending physician for the patient listed above. The declarant, the above named patient, is currently suffering from the following disease or illness:
_____________________________________________________________________________________________________________ I I I certify that I have explained to the declarant to the extent he/she is able to understand and to all available persons acting as proxy, the reasonable available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:
________directed by the declarant; or
________ that the declarant has a physical or mental condition which renders him or her unable to give personal direction for care and 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 direction concerning his/her care and treatment.
Date:_ 1/7/96Attending Physician (Signed) Robert Weitzel, M.D.
The following care and treatment is directed with respect to the declarant:
YES NO YES NO
X Do not resusitate (DNR) X Chemotherapy
X Oxygen therapy X Radiation
X Respiratory therapy
X Surgery (advise family)
X Suctioning X I.V. fluids
X Mechanical ventilation
X NG (Nasal gastric
tubes - fluids)
X CPR (Cardio-Pulmonary Resuscitation) X Gastric tube
X Chest compression X Oral Antibiotics
X Cardiac medication X I.M. Antibiotics
X Defibrillaton X I.V. Antibiotics
(Signed) ? Smith (Signed)
? Smith 1/7/96
Relationship to
declarant of Signature of declarant or authorized agent/date
any signing for
declarant
(Signed)E.Cozzins
Facility
Representative Complete Address
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12/20/95 1730 2000 2200 2330 |
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Admit note. 90 year female admitted from South Davis Hospital to room
311-2. Patient accompanied by several family members. Son signed all
paperwork. Patient was at Lakeview hospital November 1995 due to sudden
confusion, weak and incontinent.
Increased fever with expressive aphasia. CT scan revealed hemorrhage. Patient
placed in long term care where patient became
severely agitated, combative. Patient calm during intake process.
B. Hardy, RN Patient up ambulating, banging on doors. Staff redirected several times. B. Hardy, RN Patient out of bed, patient given nourishment. Speech garbled and intelligible (?) Patient responded to redirection with spitting, kicking and striking out. Ativan 1 mg intramuscularly given. B. Hardy, RN Patient resting in bed, no distress noted. B. Hardy, RN |
12/20/95
Allergies: Prozac
Admit to Geropsych unit per Dr. Weitzel
Condition: Poor
Preliminary Diagnosis: Anxiety disorder
Activity: Ad lib
Diet: Regular, soft meats
Labs:CBC, Chem 20, RPR, T7, TSH, Digoxin Level, Urinalysis with Culture and
Sensitivity if indicated EKG.
AIMES Test
Occupational Therapy evaluation and treatment.
Medication: Tylenol 1-2 by mouth every 4 hours as needed for pain.
Mylanta 30cc by mouth every 4 hours as needed for dyspepsia.
Milk of Magnesia 30 cc by mouth every bedtime as needed for constipation.
Special Precautions: Every 15 minute vital signs for 24 hours.
Vital Signs: Twice a day.
Chest X-ray
Lasix 40 mg by mouth every morning
Potassium chloride 8 meq by mouth every morning
Lanoxin 0.125 mg by mouth every morning
Normodyne 200 mg by mouth twice a day.
Vasotec 10 mg by mouth every morning.
Risperdal 0.5 mg by mouth every morning, 1700 and bedtime.
Vasotec 10 mg by mouth, every day as needed, for blood pressure greater than
175/100.
Serzone 100 mg by mouth twice a day.
Ativan 1 mg to 2 mg intramuscularly every 6 hours as
needed for severe agitation.
Telephone order Dr. Weitzel
1745 Bonnie Hardy, RN
Signed Robert Weitzel, MD
12/20/95 1815 Noted Bonnie Hardy, RN
24 hour check 12/21/95 0330 T. Scholl, RN
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12/21/95
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Free text, nights. Slept well during night, no complaints when awake,
moving about in bed, offered bathroom, refused. Diaper dry. Shelton CNA |
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12/21/95 |
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Occupational therapy initial evaluation completed. Structured
interview attempted. Patient unable to
communicate with therapist at this time. J.V...? COTA/L |
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12/21/95 |
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Psychiatric evaluation done and dictated. Has urinary tract infection.
Quite demented. Plan: Risperdol and Serzone. Treat urinary tract
infection. Robert Weitzel, M.D. |
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DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Smith, Lydia
Robert A. Weitzel, M.D.
12-21-95
CHIEF COMPLAINT
The patient is unintelligible but is reportedly quite agitated and aggressive.
IDENTIFYING INFORMATION
This is a 90-year-old widowed white female who is admitted from South Davis Hospital in Bountiful, Utah, and had apparently recently been in the Rocky Mountain Care Center.
HISTORY OF PRESENT ILLNESS
The patient had a stroke approximately four weeks ago and was in South Davis Hospital for rehab. In the past two weeks she has become severely agitated, combative, assaultive, and has been spitting and scratching at people and appeared very depressed. The patient was to be transferred to Rocky Mountain Care Center but was too combative and was a high risk potential for falls, agitation, aggression, and AWOL.
MEDICATIONS: Current medications has included Haldol 0.5 mg t.i.d. with 1-2 mg IM as p.r.n., Lasix 40 mg q. a.m., potassium chloride 8 mEq daily, Lanoxin 0.125 mg q. day, Normodyne 200 mg b.i.d., Vasotec 10 mg q. day, and then Tylenol and Serzone 100 mg b.i.d.
PAST PSYCHIATRIC HISTORY
The patient has had no previous psychiatric admissions. No previous psychiatric history of note. After her husband died she had brief psychotherapy.
PAST MEDICAL HISTORY
She had a stroke in November of 1995. Apparently had cholecystectomy this year and she is currently treated for atrial fibrillation, congestive heart failure, and hypertension. Apparently no seizures or head trauma.
Continued…….
PSYCHIATRIC EVALUATION
Lydia Smith
Page 2 …PE
Robert A. Weitzel, M.D.
SOCIAL HISTORY
She has a high school diploma and some college. She worked in real estate and had been a housewife. She is L.D.S. She is a nonsmoker, nondrinker.
FAMILY HISTORY
Negative for psychiatric disorder.
PATIENT STRENGTHS
Supportive family.
PATIENT LIMITATIONS
Aphasia, dementia, depression.
MENTAL STATUS EXAMINATION
In general this is an elderly appearing white female, who is fairly nonresponsive. Speech consists of guttural unintelligible ejaculations. Mood is fairly dysphoric. Affect is congruent. Thought process is difficult to ascertain. Thought content is difficult to ascertain. She apparently hears and sees, IQ seems grossly impaired. Calculations, memory, abstractions, fund-of-knowledge were all untestable. Insight was poor, judgement was poor.
DIAGNOSIS
Axis I: Major depression with psychotic features.
Axis II: Defer.
Axis III: Status post cerebrovascular accident, congestive heart failure, hypertension.
Axis IV: Four.
Axis V: Twenty.
DISCUSSION & RECOMMENDATIONS
We will start her on Cipro for an apparent urinary tract infection. She has been started on Haldol and Serzone will be continued. Tonight I am going to increase her Risperdol as she has been somewhat combative and difficult today. I will give her an aspirin per day against multi-infarct dementia and she will get a full medical work-up.
Continued……… PSYCHIATRIC EVALUATION
Lydia Smith
Page 3 …PE
Robert A. Weitzel, M.D.
ESTIMATED LENGTH OF HOSPITALIZATION
Three weeks.
DISCHARGE CRITERIA
No aggressiveness, improved mood.
DISCHARGE PLAN
Back to Rocky Mountain Care Center.
(Signed) Robert A. Weitzel, M.D.
RAW/lw
D: 12/21/95 22:38
T: 12/22/95 11:35
Job# 2577
_______________________________________________________________________
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1515 Behavior: Patient has been very aggressive towards staff. Patient has hit and kicked and scratched staff. Patient has not cooperated with staff's direction. Intervention - offer patient all meals and groups/ activities. Response - patient ate 100% of breakfast and 90% of lunch. Patient attended all groups and participated not very well. Plan - encourage patient to cooperate with staff's directions and continue to orient patient to surroundings. N. Hancock, CNA |
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12/21/95 1630 1745 2145
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Ativan 1 mg intramuscularly given, as patient spit out
1700 medication twice, hitting, pinching, kicking, banging at doors -
increased elopement risk, and attempting to assist another patient from
wheelchair despite staff asking her not to.
Verbal redirection not effective. D.
Kley, RN Patient sitting at table in day room with head resting on table, respirations even and unlabored Response to verbal stimuli - speech slurred, unintelligible. D. Kley, RN Patient alert, fed self. In day room watching video calmly. D. Kley, RN Behavior - patient has been very aggressive this shift. Patient has been undressing herself this shift. Patient has been hitting, spitting and kicking staff. Intervention - offered patient activities and meals. Response - patient did not attend activities, patient ate 55% of supper. Plan - observe and document activities. N. Beech, CAN |
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12/21/95
1. Cipro 500 mg by mouth twice a day for six doses.
2. Risperdol 1 mg by mouth every morning, 1700, and every bedtime.
Thanks,
Signed Robert Weitzel, MD
Noted: D Kley, RN 12/21/95 2320
12/21/95
Aspirin 1 a day by mouth
Error RW
Signed Robert Weitzel, M.D.
24 hour check 12/22/95 0430 T.
Scholl, RN
________________________________________________________________
DAVIS HOSPITAL AND MEDICAL CENTER
HISTORY AND PHYSICAL EXAMINATION
PATIENT: Smith, Lydia
Robert F. Bitner, M.D.
Admit: 12-20-95
HISTORY
This is a 90-year-old lady that was admitted yesterday for care. She is very confused and appears to be angry and resentful of anything that is being done here. She is able to walk around and seems to do so without help, although the nurses watch her and help her to move from one place to another. She is a little bit combative at times, she refused to let me do a physical examination other than just observe her general function.
I had no conversation with the family, who I am sure could give me a lot of information about the background. I understand that Dr. Weitzel will obtain information.
PAST HISTORY
I understand she has had some trouble with constipation and occasionally incontinence. She had an accident to her shoulder several years ago in a car accident and has a "frozen shoulder" because of that. She complains of no pain anywhere and no dysfunction but apparently she has been using Tylenol off and on for that.
She is quite restless and somewhat agitated as I approach her and explain who I am and so on. She is totally uncooperative other than to voice some resentment in a kind of garbled fashion that I did not understand.
Her family is interested in her care but apparently not to the point of being able to help or know what to do.
She has been said to have confusion and disorientation and in between times she becomes quite aggressive. I saw her pinching the nurse and kicking at her. I was giving her some very kind help as far as sitting, etc., but she identified anything as very negative. She has apparently been treated with Prozac in the past and is allergic to these things.
Continued….
HISTORY AND PHYSICAL
Lydia Smith
Page 2 . . . HP
Robert F. Bitner, M.D.
The history tells us that she has lost about 30 pound in the past year and there is some question about her appetite.
MEDICAITONS: Have included Haldol 0.5 mg t.i.d., Normodyne 200 mg b.i.d., Lanoxin 0.125 mg daily, potassium and Lasix are also noted. Apparently these medications are used on sort of a p.r.n. basis.
PHYSICAL EXAMINATION
GENERAL: Physically she appears to be frail but is strong enough to get up and walk around, especially with help. She shows evidence of weight loss, she is very thin but in general she is quite functional.
VITAL SIGNS: Blood pressure recorded by the nurse is 130/60 with pulse of 80 that is regular.
HEENT:
NECK:
LUNGS:
HEART:
BREASTS:
ABDOMEN:
PELVIS:
EXTREMITIES:
NEUROLOGICAL: Her mental state is pretty bad.
DIAGNOSIS
Arteriosclerotic cardiovascular disease, especially cerebral arteriosclerosis.
RECOMMENDATIONS
General care as outlined as far as nutrition and medications and just general supportive care.
(Signed) Robert F. Bitner, M.D.
RFB/lw
D: 12/21/95 13:10
T: 12/21/95 13:49
JOB #2478
___________________________________________________________
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12/22/95 |
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Patient agitated, up and down in bed assisted to
bathroom. Voided quantity sufficient. Continued
to be agitated. Ativan 1 mg intramuscularly given.
Patient ambulated in hall with assistance and returned to bed. Currently
resting quietly. T. Scholl, RN |
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12/22/95 |
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Unable to complete structured interview secondary to
impaired attention span and cognition level.
J.V...?
COTA |
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12/22/95 |
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Social Work Note: Patient unable to
complete CQI scales due to cognitive level of functioning. K.Steglich,
CSW |
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12/22/95 |
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Social Work Note: Contacted patient's son, Kent Smith, and obtained
pertinent information to complete psychosocial assessment. Family
extremely supportive.Son informed clinical
social worker that patient progressively gotten to the point where she had
to have a family member physically near her or she would become combative
and agressive. Briefly discussed possible discharge options. Son
identified Rocky Mountain Care, Bountiful or South Davis. K. Steglich, CSW |
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12/22/95 |
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Social Work Note: Patient's psychosocial assessment completed. |
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12/22/95 |
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Stable. Vital signs stable, afebrile. Pretty lethargic. Assessment -
major depressive disorder with psychotic features. Plan - Serzone and
Risperdol. Robert Weitzel, M.D. |
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1540 Behavior - patient has been very impatient and uncooperative with staff. Patient has continued to undress herself and has not talked to any staff or patients. Intervention - offered patient all groups/activities and meals. Response - patient ate 100 % of breakfast and 50% of lunch. Patient attended all groups and participated not very well. Plan - continue to encourage patient to interact more and not undress any more. N. Hancock, CNA |
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12/22/95
1900 2200 2230 2245 |
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Lung sounds decreased in left lower lobe. D. Kley, RN Ativan 1 mg given intramuscularly, right dorsal gluteal site as patient quite agitated. Hitting at staff, attempting to climb over siderails, disrupting roommate. Patient has calmed down - in bed lying down, mumbling incoherently, no longer attempting to get out of bed without assistance. D. Kley, RN Behavior - patient has been combative and physically aggressive towards staff this shift, (hitting, slapping, kicking, pinching, biting). Took her 1700 medications without combative response. Refused bedtime meds times 3 attempts. Confused. Does not participate in group. Continuously attempting to strip clothing. Intervention - attempted to administer medications as ordered. Provide groups. Verbal redirection as needed. Monitored/documented behaviors. PRN medications given as indicated. Response - patient does not respond to verbal redirection. Combative/assaultive towards staff this shift. Confused. Did not participate in group. Has stripped clothing continuously. Plan - redirect as needed. Medications as ordered. D. Kley, RN |
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24 hour check 12/23/95 0400 L. Long, RN
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12/23/95 0600 |
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Free Text: Patient slept throughout shift except when awakened for
medication at 0200 and when assisted to bathroom at 0100, where patient
voided. Patient remained continent for duration of shift. Patient took
medication in applesauce without balking. L. Long, RN |
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12/23/95 |
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Vital signs stable, afebrile. Much less lethargic. Very
demented. Digoxin level OK. . Thyroid function tests normal.
Despite pyuria, urine culture reveals no pathogens. Assessment -
tolerating medications well. Plan - Continue current care. Robert Weitzel,
M.D. |
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1300 1300 |
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(Mistaken entry, crossed out.) Behavior - patient has been very abusive today. Patient has been spitting, pinching, digging and hitting staff. Patient has been undressing self all day. Patient has been uncooperative with staff. Intervention - offered patient activities of daily living group, and meals. (Continued on other side) |
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12/23/95 1300 1600 Med Note 1630 1700 Med Note 1830 1845 1500-2300 |
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(Continued from other side) Response - patient needed maximal assist with activities of daily living. Patient attended group but was disruptive. Patient ate 70% of breakfast and 0% of lunch. Patient kept spitting out the food .Plan - follow care plan, redirect patient when aggressive. T. Sprague, CNA Free text: Patient hitting, biting, kicking other patients and staff and trying to get up without assist. Patient medicated with Ativan 1 mg intramuscularly. L. Long, RN Patient continues to try to get up without assist and tries to hit others. Patient restrained in chair with Posey belt; Dr. Weitzel notified. L. Long, RN Patient continues to be combative, agitated, trying to get up, kicking at others. L. Long, RN Patient still trying to stand without assist, mumbling angrily, spitting out food. L. Long, RN Patient assisted to bathroom, calmed down and cooperated with bedtime cares. Posey removed, assisted to bed. L. Long, RN Behavior - as above, then patient slept soundly for duration of shift. Intervention - meal, group, one-on-one, movie. Response - patient unable to track movie or group; unintelligible angry responses to all interactions. Plan - therapeutic, safe environment, medications as ordered. L. Long, RN |
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24 hour check 12/24/95 0200 L.Long,RN
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12/24/95 |
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Weekly nursing note: Patient has agitated,
angry, aggressive periods every day, usually requiring PRN medications or
restraint. Speech is unintelligible but tone is angry, exasperated.
Patient often refuses medications spitting out pills or slapping hands of
staff. Patient often spits food at staff or onto floor, often refused
proffered food or drink, muttering "I don't need," or other
garbled negative sounding declinations. Continue current care. L.
Long, RN |
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12/24/95 0100 Med Note 0200 0600 |
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Free Text: Patient awoke and became
increasingly agitated: yelling unintelligibly, trying to climb out of bed
over side rail, throwing off bed clothes. Patient medicated with Ativan 1
mg intramuscularly. L. Long, RN Patient with eyes closed, respiration even, unlabored. L. Long, RN Free text. Patient has cried several times throughout the times of 2300 - 0700, patient finally fell asleep after midnight. Patient has been toileted. Patient has been resting well. S. Thomas, CNA Behavior - patient has had episodes of agitation trying to bite and scratch staff Patient has been agitated, trying to pull out own self's hair. Patient has been alert and disoriented. Intervention - offered patient 1. Activities of daily living, 2. Group, 3. Meals. Response - Patient needs medium assist with activities of daily living, patient ate 40% of breakfast and 60% of lunch. Patient attended activities. Plan - follow care plan, redirect patient when aggressive. T. Sprague, CNA |
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12/24/95 |
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Needed a lot of Ativan last night. Striking out still.
Seems to sundown badly. Vital signs stable, afebrile. Assessment -
stable. Plan - Trazodone, routine and PRN. Robert Weitzel, M.D. |
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12/24/95
1. Urinalysis tomorrow, culture and sensitivity if indicated.
2. Trazodone 100 mg by mouth every bedtime, may repeat once as needed for sleep.
Thanks,
Signed Robert Weitzel, M.D.
12/24/95 1930 Noted Bonnie Hardy, RN
12/24/95
1. May straight catheterize for urine.
2. Posey restraint in bed tonight, for protection of
self ( against falls)
Thanks,
Robert Weitzel, M.D.
12/24/95 1930 noted B. Hardy, RN
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12/24/95 Posey on |
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Behavior - patient very aggressive,
hitting staff, spitting at staff. Patient getting out of chair, laying on
floor, refusing staff's assistance and redirection. Posey ordered to provide safety for patient and to prevent injury. Patient refused fluids. 2100 Patient offered fluids and medications. Patient spit at staff, clenched teeth, refused assistance with activities of daily living for evening. Patient was not cooperative. 2130 Patient in bed resting with eyes closed, Posey belt removed, will monitor with bed check and side rails. 2230 Patient checked for incontinence, diaper dry, patient remains quiet. Posey remains off with bed monitor and side rails for safety. Intervention - staff attempted to orient and redirect, encouraged to eat. Response - patient difficult to feed - hit staff. Would not respond to redirection. Quiet after Posey applied. Plan - monitor behavior and redirect before increase in agitation level. B. Hardy, RN |
24 hour check 12/25/95 0155 T. Scholl, RN
12/25/95
Free Text: Patient has slept through shift. Patient up times 1 to toilet.
S. Thomas, CNA
0645
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12/25/95 |
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Didn=t
need Posey last night, and has been continent |
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1000 |
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Free Text: Patient became agitated after breakfast, trying to get up without assist. Scratching and grabbing anyone within reach, trying to bite and kick others. Patient medicated with Ativan 1 mg intramuscularly and restrained with Posey belt. Conditions for release from restraint explained but patient too demented to acknowledge instructions. L. Long, RN |
12/25/95 1130
Telephone Order: Dr. Weitzel to Lynn Long, RN
If patient refuses Risperdol give Haldol 2 mg
intramuscularly.
Noted: L. Long, RN 12/25/95 1130
Signed Robert Weitzel, MD
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1100 Patient continues to refuse oral medication and tries to scratch or hit anyone who comes near. Patient medicated with Haldol 2 mg intramuscularly. L. Long, RN 1130 Posey restraint removed, patient assisted to bathroom then to bed as she is calm and drowsy now. L. Long, RN 1200 Behavior - Patient demented and agitated this shift, muttering angrily, refusing medications, trying to hit and kick staff and others,. as noted above. Intervention - offer group, movie, one-on-one, medications as ordered, restraints for patient safety. Response - patient ate 60% breakfast, (continued) L. Long, RN |
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12/25/95 NSG |
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(Continued) Day Shift Note: but 0% lunch as
patient refused anything by mouth after 0900, spitting out anything she
tasted, trying to scratch, bite, hit or kick anyone who came near. Patient
calmed down after Haldol 2 mg intramuscularly then slept until change of
shift. Plan – therapeutic, safe environment with medication as
per Dr.’ orders. L. Long, RN
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12/25/95 PRN |
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Behavior - patient throwing milk cartons
at patients and staff. Attempting to bite staff, striking out at staff.
Patient pulling arm of another patient. Not responding to staff's
redirection. Spitting and grabbing at staff when they come within reaching
distance. Ativan 1 mg given intramuscularly, three person assist to get
patient positioned, patient tolerated procedure well. 2030 Patient refuses
to take oral medication, slaps at nurse's hand, clenching teeth.
Intramuscular Haldol 2 mg given per Doctor order if patient refuses oral
medication. Patient placed in bed with 2 side rails up and bed
monitor. Intervention - provided medications as ordered. Spoke in a calm,
clear voice, maintained a safe distance. Reduced stimuli. Response -
patient did not respond to interventions not involving medications. Patient
decreased aggressive acts after injections. Plan - monitor and
prevent escalation. B. Hardy, RN |
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24 hour check 12/26/95 0115 T. Scholl, RN
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12/26/95 0200
11-7 |
Patient agitated. Repeatedly attempting to
get out of bed. To bathroom with assist. Ambulated in hall with
assist. Striking out at staff, kicking.
Throwing clothing. Ativan 1 mg
intramuscularly given as ordered. T. Scholl, RN Free text - Patient calmed after receiving Ativan. Appeared to sleep quietly remainder of night with respirations even and unlabored. T. Scholl, RN Behavior - patient has had no aggressive behavior today. Patient has been sleepy and hard to arouse. Patient has been cooperative after breakfast. Intervention - offered patient activities of daily living group, meals. Response - patient needed medium assist with activities of daily living. Patient ate 0% of breakfast and 20% of lunch. Patient attended and participated in group. T. Sprague, CNA
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12/26/95 |
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Does pretty well with some Haldol;
without major extrapyramidal symptoms. Can be
quite aggressive, and is very demented and primitive. Vital signs
stable, afebrile. Assessment - stable. Plan - continue current care.
Robert Weitzel, M.D. |
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12/26/95 2150 |
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Behavior - patient showed very aggressive
behavior this shift. Patient continued to undress herself, patient was
also hitting, pinching and kicking. Also trying to bite staff and other
patients. Intervention - patient was placed in a Geriatric chair,
patient was redressed. Patient was also allowed to walk up and down hall
while staff was watching her and helping her. Response-Patient
became somewhat more combative. Plan - continue with medications
per Doctor's orders, continue to observe patient's behavior, watch for any
medication side effects. |
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24 hour check 12/27/95 0145 B. Hardy, RN
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12/27/95 11 - 7 |
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Free text: Night. Slept well until 0200 then slept short intervals,
restless, taking clothes and cover off. Once when up to bathroom,
tried to sit on the floor, on return
back to bed, continued restlessness and
disoriented. D. Shelton, CNA Free text medication entry: Refused all medications, hitting and spitting at staff. Given Haldol 2 mg intramuscularly at 1000. Patient calm and took medications crushed in applesauce. S. Hansen, RN |
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12/27/95 |
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Continues to be aggressive and psychotic.
Vital signs stable, afebrile. Very demented,
mood dysphoric. Assessment - major depressive disorder with psychotic
features. Plan - continue current care. Robert Weitzel, M.D. |
AUTOMATIC DRUG STOP ORDER
Patient: Lydia Smith Room 311-2
Drug(s) Exp. Date Last Dose
1. Ativan
1-2 mg IM q 6 hrs prn agitation
2.
3.
4.
According to hospital policy orders for
these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
Expiration Date
12/27/95
Noted: 12/27/95 1100
Sheila Hansen, RN
12/27/95
Sputum culture: Signed Robert Weitzel, MD
Noted 12/28/95 0100 T. Scholl, RN
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900 Behavior - patient was agitated in the morning then after Haldol was given patient calmed down. Patient was uncooperative with staff when staff tried to button up shirt. Patient has been drowsy after medications were given. Intervention - offer patient activities of daily living, meals, group. Response - patient needed maximum assist with activities of daily living. Patient ate 5% of breakfast and 40% of lunch. Patient attended group but was disruptive during group so patient had to leave group. Plan - follow care plan, redirect patient when agitated. T. Sprague, CNA |
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12/27/95 2145 2100 Medication note |
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Behavior - patient was calm until mealtime.
After supper became increasingly agitated as time went on. Was scratching,
hitting and generally physically abusive after family left in
evening, refused evening medications. Intervention - RN medicated
per Doctor's orders for agitation. Attended groups and ate 80% of
dinner. Response - took oral medications after intramuscular medication
intervention at which time the agitation gradually decreased. Was climbing
out of bed for over an hour setting bed alarm off, but finally did relax
and go to sleep. Plan - patient needs to take evening medications as
ordered to keep behavior from escalating in the evenings. R. Huggins, CNA Late entry: Free text medication note. Patient refused evening medication plus was aggressive towards staff and agitated. Medicated with Haldol 2 mg intramuscularly as per Doctor's orders. One hour later at 2200 patient compliant with request that she take oral medication. L. Long, RN |
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24 hour check 12/28/95 0140 T. Scholl, RN
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12/28/95 |
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Free text: night. Slept fair. Up to bathroom twice, restless on return
from bathroom for about an hour then slept remainder of night. No
agitation when up. D. Shelton, CNA |
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12/28/95 Dietary |
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Nutrition Update: Weight is 115.6 lbs. Admission weight 116 lbs.
Patient's oral intake varies greatly from 0 to 100 percent. Patient
refuses some trays and spits out food when agitated. Plan - will
continue to offer 3 meals daily and bedtime snack. Will monitor intake and
changes in weight. R. Warner, Nutritionist |
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12/28/95 |
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Occupational Therapy Weekly Note: Patient
requires multiple verbal cues to arouse. Once aroused, patient is
preoccupied with |
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12/28/95 |
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Doing better, much less irritable, has hit no one today. Vital signs
stable, afebrile. Quite demented. Assessment - stable. Plan - continue
current care. Robert Weitzel, M.D. |
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1510 Behavior - patient
has been stubborn and ornery during this shift. Patient has struck out at
staff and has yelled and been disoriented. Intervention - offered
patient all meals and groups/activities. Response - patient ate 100% of
breakfast and 60% of lunch. Patient has attended a few activities, and did
not participate in these. Plan - continue to encourage patient to not
strike out and attend more groups. N. Hancock, CNA |
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