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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24
hour check 12/29/95 0240 T. Scholl, RN
12/29/95
24 hour check 12/30/95 0615 T. Scholl, RN
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12/30/95 |
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Very variable behavior. Daughter's here to visit, we
talked briefly. Getting about half of her anti-psychotic (medication) via
intramuscular Haldol until today, when she took oral Risperdol;
and behavior has been good today. Vital
signs stable, afebrile. Assessment - stable. Plan - continue current care.
Robert Weitzel, M.D. |
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AUTOMATIC DRUG STOP ORDER |
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AUTOMATIC
DRUG STOP ORDER |
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AUTOMATIC DRUG STOP ORDER
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24 hour check L. Wilson, RN 12/31/95 0145
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12/31/95 |
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Night shift free text note. Patient rested quietly throughout most of
shift. Awake once at 0300. Disoriented to person, place, time and
situation. Oriented with soothing from nursing staff. L. Wilson, RN |
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12/31/95 |
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Taking medications all right.Vital signs stable. Afebrile. Slept
through the night. Mildly lethargic, arouses easily. Eating well.
Assessment - stable. Plan - continue current medications. Robert Weitzel,
M.D. |
AUTOMATIC DRUG STOP ORDER
Patient: Lydia Smith Room
Drug(s) Exp. Date Last Dose
1. Risperdol 1 mg po q am, 1700, hs
2. If pt refuses give Haldol 3 mg IM (see PRN)
3.
4.
According to hospital policy orders for these medications must be reordered or
they will be discontinued.
Signature: Robert Weitzel, M.D.
12/31/95 1345 Noted B. Hardy, RN
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1500 Behavior - patient was agitated and aggressive at breakfast, taking clothes off and hitting at staff. Ate most of breakfast on own, spit out some of morning medications. Needed constant supervision in order to keep from harming self and others. Intervention - encouraged to eat breakfast and take pills. Encouraged to converse with nurse to help calm down, was about to medicate with Haldol 3 mg intramuscularly relative to didn=t take all medications. Patient fell asleep in chair in day room after breakfast, therefore did not give Haldol. Response - was calm after woke up from morning nap, more cooperative than has been past few days, interacted more with staff. Plan - continue to encourage food/ fluid intake. Encourage interaction with staff and group and to keep clothes on. J. Jensen, LPN |
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12/31/95 |
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Behavior - patient attended group and movie but many times got up to
wander. Patient was compliant with redirection and taking oral medications
at dinner but as shift progressed became
increasingly agitated: banging on exit doors, trying to slap CNA and RN,
ranting in agitated tones her non-sensical objections to redirection or
offer of food or water. Patient refused bedtime medications. Intervention
- offered meal, snack, group, movie. Patient
medicated with Haldol 3 mg intramuscularly per Doctor's as needed order.
Response - patient ate 70% of dinner, 100% snack, and calmed down after Haldol, eventually taking bedtime medication Plan-therapeutic
safe environment, medications as ordered. L Long RN |
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24 hour check L. Wilson, RN 0700 1/1/96 |
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1/1/96 11 - 7 |
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Night shift free text note: Patient rested quietly throughout the
shift. Not roused by every 15 minute nursing checks. L. Wilson, RN |
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Medication note: Patient refused medications and was given 3 mg Haldol intramuscularly. Patient refused medications 1 hour after Haldol given. R. Clark, LPN Medication note: patient medicated for escalating agitation at 1510 as evidenced by hitting other patients, pacing, rattling doors. R. Clark, LPN Behavior - patient was pacing much of morning. Little interaction. Angry affect. Intervention - meals, medications, groups, one-on-one time offered. Offered patient pen and paper for writing to distract from pacing. Response - patient aggressive when redirected, striking out, patient refused all oral medications and assistance with meals; patient only distracted momentarily with paper and pen. Plan - continue to try different methods to increase compliance with medications. R. Clark, RN |
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1/1/96 |
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Behavior - patient was agitated and
aggressive all shift, with no effects of 1500. Ativan noted as far as
improvement in patient's mood. Patient refused all oral medications and
any thing else offered, tried to punch staff, open exit doors.
Intervention - patient medicated with Haldol 3
mg intramuscularly at 1700 due to refusal to take medications and general
agitated behavior. Response - patient
only calmed down at 2100 and compliantly took evening medications then,
although patient was taking off her clothes in bed, muttering
incoherently. Plan - therapeutic safe environment. L. Long, RN |
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1/1/96 |
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Slept through the night. Has been refusing
medications again and was quite recalcitrant, got aggressive this evening
and received Ativan intramuscularly, which helped. Vital signs
stable. Afebrile. Assessment - remains labile and intermittently agressive.
Plan - increased Depakene. Robert Weitzel, M.D. |
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1/1/96
1. Increase
Depakene to 250 mg by mouth every morning, 250 mg by mouth every 1700 and
Depakene 500 mg by mouth every bedtime.
2. Please get Valproic Acid level in
morning on 1/4/96.
Thanks, Robert Weitzel, M.D.
Noted: L. Long, RN 1/1/96 1730
1/1/96 2300 Telephone order Dr.
Weitzel
If patient refuses
Risperdol give 5 mg intramuscular Haldol.
Signed Robert Weitzel, MD
Noted: L. Long, RN 1/1/96 2300
1/2/96 0100 24 hour (check) L. Wilson, RN
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1/2 /96 |
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Night shift free text note: Patient rested quietly most of shift.
Awake once at 0400. Assisted to toilet. Returned to bed and remained quiet
for rest of shift. L. Wilson, RN |
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1/2/96 |
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Weekly RN advocate note: Patient has
persisted in her refusal to take medications. She has required many doses
of intramuscular Haldol as a result. Her aggressive behavior continues.
Her behavioral (continued) (L. Wilson RN) |
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1/2/96 |
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(continued) goals have not been met.
L. Wilson, RN |
1400 Behavior - Patient
has taken her medications after much prompting by medication nurse. Intervention
- support. One-on-one time. Limit setting. Response - oppositional,
hitting and kicking at staff and other patients. Plan - medications as
per doctor. Therapeutic
environment. E. Cozzins, RN
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1/2/96 |
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Disoriented, confused, demented.
Did sleep through night after a difficult evening. Vital signs stable,
afebrile. Assessment - stable. Plan - continue current care |
1/2/96 1630
Order clarification: If
patient refuses Risperdol by mouth give 5 mg Haldol intramuscularly.
Telephone order Dr. Weitzel, B. Hardy,
RN
Signed Robert Weitzel, MD
1/2/96 noted B. Hardy, RN 1630
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1/2/96 3 - 11 |
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Behavior - patient very drowsy during first half of shift, during
second half patient agitated and refused
medications by mouth. Family member tried
to feed patient food. Patient still refused to open mouth for anything. No
dinner eaten. Patient up ambulating in hallway with unsteady gait.
Haldol 5 mg intramuscularly given per Dr. order when patient refuses oral
Risperdol. Patient got out of bed 3 times. Undressed
self and pulled gown up. Patient sleeping currently. Intervention -
gave patient activity of daily living cares, attempted to give oral
medication, provided as neede' medication, and redirected twice. Response
- patient refused oral medications, would not respond to staff's
redirection. Patient settled into bed at 2130. Plan - observe behavior,
report findings to Doctor daily. B. Hardy, RN |
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24 hour check 1/3/96 0310 T. Scholl,
RN
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1/3/96 11 - 7 |
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Free text - patient very restless, sitting
up in bed, restlessly attempting to get out of bed. Patient up
ambulating in hall with assistance. Striking
out, kicking at staff and attempting to step on staff. Intramuscular
Haldol given as ordered for severe agitation.
Patient slept quietly remainder of night, respirations even and unlabored.
T. Scholl, RN |
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1/3/96 |
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Apparently misses many doses of her medication secondary
to noncompliance, then is mildly labile and irritable.
Vital signs stable, afebrile. Assessment - Still
quite dysphoric and intermittently psychotic. Plan - Increased Serzone, add Trazodone in daytime, Clonidine patch might
help. Thanks, Robert Weitzel, M.D. |
AUTOMATIC DRUG STOP ORDER
Patient: Lydia
Drug(s) Exp. Date Last Dose
.Trazodone 100 mg qhs 1/3
2.Trazodone 100 mg qhs MRx1 prn sleep
1/3
3.Ativan 1-2 mg IM q6 prn severe agitat.
1/3
4.
According to hospital policy orders for
these medications must be reordered or they will be discontinued.
Signature: Robert Weitzel, M.D.
1/3/96
1. Serzone
150 mg twice a day
2. Trazodone
50 mg by mouth every morning 50 mg by mouth every 1700 and 150 mg by mouth every
bedtime.
3. Depakene (Valproic acid) level in
morning
Thanks, Robert Weitzel, MD
1/3/95
Clonidine transdermal
patch 0.2 mg per dermis every 3 days. Error R.W. every week.
Thanks, Robert Weitzel, M.D.
1200 1/3/96 (Nurse, signature cut off
page)
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1300 Behavior - patient refused morning medications. Patient has been very aggressive, hitting, kicking and biting staff. Patient very difficult to redirect. Intervention - support. One-on-one time. Intramuscular medications. Safe environment provided. Response - very aggressive and agitated. Pacing very confused. Not oriented to time, place or person. Plan - medications as per Doctor. Safe therapeutic environment. E. Cozzins, RN Late entry, medication note: patient refused morning medications or anything by mouth (continued) L. Long, RN |
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1/3/96 1200 1300 |
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(continued) plus was trying to hit and
spit at staff and other patients. Patient medicated with Haldol 5 mg
intramuscularly. L. Long, RN Free text: patient still refusing medication or anything offered by staff, in demented, disoriented fashion, muttering incoherently but automatically trying to slap away hand of staff. No discernable decrease in agitation since Haldol intramuscularly. L. Long, RN Free text: patient's agitation increasing: hitting, biting, kicking, spitting at staff and other patients. Patient medicated with Ativan 2 mg intramuscularly, with immediate results: patient calm, not agitated or aggressive. L. Long, RN Free text - patient took morning medications without complaint. L. Long, RN |
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1/3/96 |
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Behavior - patient very drowsy in Geriatric chair at start of shift.
Patient did not eat dinner due to lethargic state. Patient placed in bed.
When taken to bathroom, patient would pick up both legs and bend them.
Staff had to support for entire ambulation transaction.
Intervention - gave Haldol intramuscularly due to patient not taking
medications by mouth, provided evening care and assistance with all cares.
Response - Patient would not allow any oral
medications. Patient clamped teeth shut and attempted to grab at staff.
Patient got out of bed twice, sitting on edge,
and would not ambulate with staff assistance to bathroom. Defiant of
staff's efforts displayed by raising legs while ambulating. Plan -
moniter effects of intramuscular Haldol. B. Hardy RN Med Note: Patient given Haldol 5 mg intramuscularly when medications refused per Doctor's order. R. Clark LPN |
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24 hour check 1/4/96 0415 T. Scholl, RN
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1/4/96 0600 11 - 7 |
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Medication note - patient restless,
tossing and turning. Up to bathroom, biting at staff, striking out and
kicking. Returned to bed and intramuscular Ativan given as ordered. T.
Scholl, RN Patient calmer but continues to have difficulty sleeping. T. Scholl, RN Free text - patient appears to be sleeping quietly since 0630. Side rails up bed check in place. T. Scholl, RN Behavior - patient has been lethargic during the shift. Patient has
been nonresponsive to staff. Patient has been sleeping all shift.
Intervention - offered patient activities of daily living, group, meals.
Response - patient needed maximum assist with activities of daily living.
Patient ate 0% of meals, because patient would not arouse to meals.
Patient attended group but slept through group. Plan - follow care plan,
encourage patient to stay awake and eat meals. T.
Sprague, CNA |
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1/4/96 |
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Remains recalcitrant. Climbing
out of bed in early morning, virtually entangled in bed rails. Very
poor judgment. Vital signs stable, afebrile. Assessment - remains symptomatic. Plan
- observe on increased Serzone/ Trazodone,
added Clonidine. Robert Weitzel, M.D. |
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1/4/96 2220 |
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Behavior - patient has been quiet this shift, dozing on and off. No
physical aggression towards staff this shift. Refused 1700 medications.
Took bedtime medications except Depakene syrup. Did not participate in
group. Intervention - administered medications as ordered. Provided group.
Monitored behavior. Response - patient quiet this shift. Dozed on and off.
No episodes of physical aggression noted toward staff. Refused 1700
medications, took most of her bedtime medications. Went to bed with
assistance from staff without problems. Did not participate in group. Plan
- continue to administer medications as ordered. Provide group. Monitor
behaviors. Encourage socially appropriate behaviors - redirect as needed.
D. Kley, RN |
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1/4/96 |
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Occupational therapy weekly summary: Patient attends occupational
therapy group sessions, patient unable to
participate secondary to her being preoccupied with doffing clothes.
Patient requires to require verbal cues with moderate assist to arouse and
attend. Patient continues to demonstrate increased frustration and
increased agitation when aroused. J.V. ...? COTA/L |
24 hour check 1/5/96 0420 T. Scholl, RN
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1/5/96 0230 0700 |
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Medication entry - patient very agitated,
making numerous attempts to get out of bed. Striking at staff. Resisting
assist to bathroom. Haldol 1 mg intramuscular given for severe agitation.
T. Scholl, RN Patient has been sleeping quietly since 0145. Respirations even and unlabored. Both side rails up. Bed check monitor in place. T. Scholl, RN Patient continued to toss and turn but less restless and did sleep for short periods of time. T. Scholl, RN |
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1/5/96 |
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Very obstinate, angry.
Vital signs stable. Afebrile. Very demented.
On Depakene, Clonidine, Serzone, Risperdol, Trazodone; but continues to be
very negative. Taking medication today. Assessment - stable. Plan -
continue current care. R. Weitzel, M.D. |
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7 –3 Behavior - patient very lethargic this shift, sitting with eyes closed, trying to remove clothing, socks; batting away any offered snack or beverage, mumbling incoherently. Intervention - offered group, one-on-one, assistance with all activities of daily living. Response - patient unresponsive verbally and hit out whenever cares given, food offered. Plan - therapeutic safe environment, medications as ordered. L. Long, RN
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24 hour check 1/6/96 0255 T. Scholl, RN
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1/6/96 1415 |
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Free text - patient awakened once during the night - attempting
to remove diaper. Taken to bathroom on potty chair - voided.
Continent through the night. Patient returned to bed and slept quietly
remainder of night. No problems noted. T. Scholl, RN Behavior - patient has not been agressive. She has been sleeping most of day. When awake she has kept trying to strip. When offered meals she has spit it out at us. Intervention - offer groups and meals. Response - patient slept through most everything. Plan - continue to offer group and meals. Angie Kennedy, CNA |
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1/6/96 |
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Late entry for 1/5/95 Social Work Weekly Summary - Patient
has not attended group therapy or participated in individual therapy due
to lethargy. When attempts are made to arouse patient she displays minimal
responses. Patient continues to refuse to take medications. Patient
consistently tries to remove clothes and continues to be aggressive and
agitated with staff. Patient confused, disoriented, and when she does
communicate she mumbles incoherently. Family involved in discharge
planning. K. Steglich, CSW |
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1/6/96 |
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Social Work Note: Spoke with patient's daughter, Bonnie, via phone.
Provided her with education regarding potential nursing homes for patient
after discharge from hospital. Addressed her questions and concerns
related to nursing home placement. Met with patient's son Kent and his
wife and discussed patient's status. He
verbalized concerns about patient's physical status. Encouraged him
to contact Dr. Weitzel Monday morning to discuss patient's medical status. |
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1/6/96 |
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Social Work Note Continued - Kent very
realistic about patient's declining mental status. Provided
supportive counseling. Educated him regarding potential nursing home
options. Scheduled tentative family conference for 1/10/96 to review
patient's progress and confirm patient's disposition after discharge from
Geropsych unit. K. Steglich, CSW |
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1/6/96 |
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Feeding poorly, lethargic.
Ambulating a bit Vital signs stable, afebrile. Assessment - stable. Plan -
continue current care. Robert Weitzel, M.D. |
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1/6/96 |
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Behavior - patient has been quiet this shift. Rested quietly with eyes
closed most of shift, respirations even and unlabored. Ate none of supper.
No episodes of combativeness. Took medications as ordered. Intervention -
administer medications as ordered. Provide group. Monitored behaviors.
Response - patient appeared to sleep most of this shift as evidenced by
resting quietly with eyes closed, respirations even and unlabored. Slept
in chair at supper, ate nothing, took
medications as ordered Did not interact in group. No combative episodes
this shift. Plan - continue to administer medications as ordered. Provide
groups. Monitored behaviors condition. Reorient. Redirection as needed. D.
Kley, RN |
24 hour check 1/7/96 2400 L. Wilson, RN
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1/7/96 1400 |
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Night shift free text. Patient rested quietly throughout shift.
Minimally responsive to morning cares (bed scale weight, vital signs,
diaper change). Respirations slow, deep and regular. Keeps eyes closed
most of the time. No combative behavior. Posture
is rigid at times. L. Wilson, RN Behavior - patient not able to take medications. Patient lethargic and unresponsive. Patient not swallowing or responding to staff. Intervention - patient=s family notified of patient's condition. Family in to be with patient. Oral care given. Doctor called (unknown word) twice without calling back. Response - no wet diapers. No oral intake. Plan - turn every 2 hours. Good activity of daily living care. Follow Doctor's orders. E. Cozzins, RN |
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1/7/96 |
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Very weak, not taking any nourishment, no urine output.
Family discussion with 2 sons and daughter
reveals that they don't want her life prolonged, but are ready to let her
go. At times she thrashes about, seems to
be in pain/anxiety. Assessment - quite
ill. Plan - hold medications, morphine
sulfate 5 mg every 3 hours intramuscularly. Robert Weitzel, M.D. |
1/7/96
Morphine sulfate 5 mg
intramuscularly every 3 hours around the clock.
Thanks, Robert Weitzel, MD
1/7/96 Hold
all other meds (other than Morphine sulfate)
Do not resuscitate
Thanks, Robert Weitzel, MD
1/7/96 Earline Cozzins, RN 2130
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1/7/96 |
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Behavior - patient not able to take any medications.
Patient unresponsive most of the shift.
Intervention - support. One-on-one time. Medications as per Doctor. Family
and Doctor notified of patient's condition. Response - family
and Dr. Weitzel in to see patient. Respirations shallow. Plan - comfort
measures. E. Cozzins, RN |
1/8/96 24 hour check 0200 L. Wilson, RN
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1/8/96 |
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Night shift free text note. Patient lying in bed with eyes open
throughout shift. Demonstrates much reflexive grasping in response to
physical stimuli. Unable to make any verbal response. Morphine sulfate every 3 hours intramuscularly as scheduled for comfort.
2400 dose omitted due to patient appeared in no acute distress at the time
and nursing staff was attending another dying patient and her
family. 0300 dose given at 0230. Respiration
rate 10 to 12. Apneic periods from 10 to 20 seconds. Long period
Cheyne-Stokes respirations. After 0500 respirations 14 to 16, slow, deep
and regular, without waxing and waning pattern. L. Willson, RN |
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1/8/95 0900 |
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1200 1245 |
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Respiration relaxed. Daughter at bedside. Skin pale. L. Willson, RN Patient's daughter requested us to check patient. States "I don't
think she is breathing." Patient checked. No respirations. No pulse.
Patient placed on her back with hands to side, teeth placed in mouth. ? RN |
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1/8/96 1255 1330 1430 1350 |
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Emergency room Doctor notified to pronounce patient dead. Nursing
supervisor notified. Daughter notified. ? RN Dr. Weitzel notified by phone of patient death. ? RN Nursing gathering up patient items. Family given all of patient's things. Waiting for mortuary to come and take patient. Patient has been cleaned up. Diaper changed. Daughter and son in room. ? RN Patient taken out via gurney with Allen Hall Mortuary. Family took all belongings home. ? RN Late entry. Emergency room Doctor came to officially pronounce patient dead. ? RN |
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1/8/96 |
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Social Work Note - Met with patient's daughter-in-law, granddaughter
and daughter. Provided bereavement and grief counseling. Discussed grief
issues and provided support. K. Steglich, CSW |
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1/8/96 1350
Asked to see patient
No vital signs
Patient with family
Plan - Discharge to mortuary
Signed, Dr. B. Nielson, MD
1/8/96 1350 (Unknown Nurse Signature
1/9/96
Release patient=s
body to mortuary
Signed Robert Weitzel, MD
Noted 1/9/96 1230 Sheila Hansen, RN
DAVIS HOSPITAL AND MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: SMITH, LYDIA
ROBERT WEITZEL, M.D.
ADM: 12/20/95
DIS: 1/9/96
HISTORY
The patient was admitted with a diagnosis of anxiety disorder.
HOSPITAL COURSE
She was started on Lasix 40 mg q. a.m., potassium chloride 8mEq q. a.m., Lanoxin 0.125 q. a.m., Normodyne 200 mg b.i.d., Vasotec 10mg q. a.m., Risperdol 0.5mg q. a.m., 1700, and h.s., Vasotec 10mg q.day p.r.n. blood pressure greater than 175/100, Serzone 100 mg p.o./b.i.d..
On admission her chemistries were fairly normal except for an elevated glucose and BUN. TFTs were within normal limits. A digitalis level on the 21st was 0.5. Valproic acid on the 4th of January was 37.4. Chest x-ray really unremarkable. Initial urine was pyuric, RPR non-reactive. Repeat urinalysis on the 25th revealed low amount of white cells and some epithelials consistent with a non-sterile collection.
On the 21st she was started on Cipro 500 mg b.i.d. and Risperdal was increased to 1mg .a.m., 1700 hours, and q.h.s. – may repeat times one. On the 25th we ordered Haldol given if patient refused Risperdal. She frequently did refuse oral medications. On the 29th Depakene was started at 125mg q. a.m., 1700 hours, and 500mg q.h.s. and Haldol was increased to 3mb IM if patient refusing oral Risperdal and Haldol 5mg p.o. or IM as ordered p.r.n. severe agitation as well as some Cogentin as a p.r.n. On the 1st Depakene was increased to 250 mg. Q.a.m., 1700 hours and 500 mg q.h.s. and of course a level was ordered for the 4th which was slightly low. On the 3rd Serzone was increased to 150mg q.h.s. and a Clonidine transdermal patch was ordered 0.2mg one per dermis q. week.
The patient became quite ill on the 7th and was not taking any nourishment or fluids and had no urine output. After a family discussion with her two sons and daughter, the family decided that they did not want her life artificially prolonged, but rather would like comfort care.
C O N T I N U E D ……
DISCHARGE SUMMARY
DAVIS HOSPITAL AND MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: SMITH, LYDIA
PAGE 2 . . .
At that time she was thrashing about in apparent pain and anxiety and her medications were changed so that all usual meds were held but rather she was given Morphine Sulfate 5 mg q. 3 hours IM. On the 8th she was once again unresponsive for the most part. She appeared to be in some discomfort at times and so Morphine sulfate was increased to 10mg q. 3 hours. On the morning of the 8th she died of respiratory arrest. Dr. Nilson was kind enough to come and sign off for usual paperwork.
The body has been released to the mortuary.
DISCHARGE DIAGNOSIS
Axis I: Anxiety disorder, NOS.
Axis II: Defer.
Axis III: Hypertension, congestive heart failure.
Axis IV: Four.
Axis V: Zero, zero on discharge.
(Signed) Robert Weitzel, M.D.
RW/rn
D: 01/09/96 6:19
T: 01/10/96 5:28
JOB # 5375
(Insert Medication Administration Record)