Mary Crane

Brief History and Hospital Course

This 72 year old white female who had history of severe dementia, depression, agitation and combativeness suffered thalamic CVA in 1989, six years PTA, and had history of severe chronic low back pain after disc surgery, treated generally with opiates daily for years. She had chronic hyponatremia secondary to psychogenic polydipsia; she was reported to drink even from toilets, when on therapeutic fluid restriction, unless restrained. She also had history of HTN, PUD, meningitis, TIA’s, and psychotic depression. On admission her medications included Dyazide, Lasix, Glucotrol, Hyphen, Lopressor, Zantac, prn Lortab, as well as Thorazine, Zoloft, Tranxene, and prn Xanax.

Previous medications were continued but Duragesic patch 25 mcg./hour then 50 mcg./hour was substituted for Hyphen and Lortab. K-Dur was added, and Risperdal and Serzone were substituted for her previous psychotropics; she also was given trazodone for sleep. A UTI was treated with Cipro, Dyazide was discontinued, and hyponatremia treated with fluid restriction. Despite these measures, her psychiatric symptoms continued.

A rectovaginal fistula was discovered, GYN consulted, and she was started on Keflex. Because of history of possible seizure disorder, and valproate’s effect with aggressive agitation, Depakene was added. The patient continually complained of pain; moaning, groaning, and screaming, and had morphine prn’s given by the nurses, then Duragesic patch increased to 75 mcg./hour.

On about the eighth hospital day, on the 4^th, the patient apparently aspirated; CXR was clear but clinically she had breathing and airway problems and was choking on her food. This continued and then on 1/7, her eleventh hospital day, she became acutely and seriously ill, with hypernatremia (sodium of 159) white count up at 15K, hypotensive, and oxygen saturation of only 70 to 80. CXR showed a possible infiltrate. She appeared septic, secondary either to aspiration or the rectovaginal fistula, despite Keflex started previously.

The patient’s family refused aggressive intervention, and an IV was not started, following her Medical Treatment Plan. All medications, including her Duragesic patch, were ordered to be discontinued. She did have ordered and received two doses of morphine 5 mg. IM at that point, apparently in conjunction with the Duragesic, which the nurses failed to remove and which was found at autopsy. She died the evening of the 7^th, with her family at her side.

Mary Crane Phone Intake Data

DAVIS HOSPITAL AND MEDICAL CENTER GEROPSYCHIATRIC UNIT

1600 WEST ANTELOPE DRIVE

LAYTON, UTAH 84041

MEDICAL TREATMENT PLAN

Patient’s name: Mary Crane Date: 12/28/95

I, 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 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: 12/30/95Attending Physician: (Signed) Robert A. Weitzel, M.D.

The following care and treatment is directed with respect to the declarant:

YES NO YES NO

X ____ Do Not Resuscitate (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 tube - fluids feeding)

____ X CPR (CardioPulmResusc) ____ X Gastric tube

____ X Chest compression X ___ Oral Antibiotics

____ X Cardiac medication X ____ I.M. Antibiotics

____ X Defibrillation X ____ I.V. Antibiotics

(signed )Karen Bringhurst

Relationship to declarant of Signature of declarant or authorized agent/date

any signing for declarant

E. Cozzens, R.N.2499 Builders Drive, S.L.C. UT 84118

Facility Representative Complete Address

The following care and treatment or withholding of treatment is directed with respect to the declarant:

YES NO YES NO

X ____ oxygen therapy ____ X IV fluids

X ____ respirator treatments ___ X NG (nasal-gastric tube

X ____ suctioning for fluids feedings)

____ X mechanical ventilation ____ X gastric tube (for feedings/fluids)

____ X ventilator support X ___ oral antibiotics

____ X CPR X ____ IM antibiotics

____ X chest compressions X ____ IV antibiotics

____ X cardiac medications ____ X defibrillation

during CPR ____ X surgery

____ X chemotherapy ____ X radiation

Date: 3/22/91Attending Physician: Sara Anderson M.D.(?)

Self (Signed) Mary R. Crane

Relationship to declarant of any Signature of declarant or authorized agent

agent signing for declarant

Address of signer, including city, country and state of residence

Mary Crane Nursing Admission Assessment Page 1

Mary Crane Nursing Admission Assessment Page 2

Mary Crane Nursing Admission Assessment Page 3

Mary Crane Nursing Admission Assessment Page 4

Mary Crane Nursing Admission Assessment Page 5

Mary Crane Nursing Admission Assessment Page 6

Mary Crane Nursing Admission Assessment Page 7

Mary Crane Nursing Admission Assessment Page 8

Mary Crane Nursing Admission Assessment Page 9

Mary Crane Nursing Admission Assessment Page 10

Mary Crane Nursing Admission Assessment Page 11

Mary Crane Nursing Admission Assessment Page 12


12/28/95 1800		PRN medication given: Tylenol 650 mg by mouth given as ordered as patient complains of headache. D. Kley, RN
2000		Tylenol helpful. Patient complains of "still have headache, but it's better." D. Kley, RN

1600

Admission note. Behavior. Patient admitted to Geropsychiatry with diagnosis of depression with psychotic features. Long history of depression and psychiatric interventions. Has worked as LPN until death of her husband, then unable to cope with the stress. Comes to us from care center, where she has been biting, kicking, and verbally abusing staff. History of hyponatremia - craves fluids enough to drink from toilets when fluids are restricted. Has had seizure secondary to hyponatremia "in the past". Intervention - oriented patient and family to unit layout and policies. Completed admission assessment. Belongings inventoried.. 1800 calorie ADA diet provided. Duragesic patch instituted for chronic back pain due to old disc injury. Response - patient calmer, more quiet in late evening. (earlier yelling quite a bit). Does eventually respond to comfort measures. Plan- see treatment plan. L. Wilson, RN

12/28/95

Psychiatric evaluation done and dictated. Diagnosis: major depressive disorder with psychotic features. Plan - Risperdol / Serzone,/ Trazodone. Medical workup. Duragesic for pain. Robert Weitzel, M.D.

DAVIS HOSPITAL & MEDICAL CENTER

PSYCHIATRIC EVALUATION

PATIENT: Crane, Mary

Robert A. Weitzel, M.D.

12/28/95

CHIEF COMPLAINT

"Put me to bed, I just want to go to bed."

IDENTIFYING INFORMATION

This is a 72 year-old widowed white female who had recently been at Sandy Regional.

HISTORY

This patient had been on the Alzheimer’s unit after having had a stroke in 1989. She has been extremely agitated, spitting, aggressive, drinking out of the toilet, hitting, verbally abusive, running into others with her wheelchair and screaming. She sticks her fingers down her throat to throw-up. She is very anxious, agitated, and complains of low back pain and headaches. She has been transferred to our unit for treatment of her depression and psychotic features.

PAST PSYCHIATRIC HISTORY

Apparently she has had a long history of previous depression. Currently she is on no antidepressants. She also has a history of apparent psychogenic polydypsia with hyponatremia, down to 108 and there were seizures associated with this. I have no clear history as to her previous psychiatric medications or antidepressants. I do have a report that she had been on Thorazine for some time and she does exhibit some signs of tardy dyskinesia.

PAST MEDICAL HISTORY

She had a stroke in 1989, has had a herniated disc in 1984, and poor control of her pain since then. She had a gastrectomy in the 1980’s, secondary to history of GI bleeds. She has been treated for this with Zantac and Carafate. As noted above, she has had chronic low sodium because of polydypsia.

Continued…..

PSYCHIATRIC EVALUATION

Mary Crane

Page 2 … PE

Robert A. Weitzel, M.D.

MEDICATIONS: Current medications include Zantac 150 mg b.i.d., Lopressor 100 g b.i.d., Glucotrol 5 mg q. a.m., Hyphen one tablet p.o. q. 4. hours p.r.n. pain, Dyazide one p.o. q.o.d., Lasix 30 mg p.o. q.o.d. (Dyazide and Lasix on alternate days), artificial tears, Carafate, Metamucil, ferrous sulfate.

SOCIAL HISTORY

As noted above, she is a widow, she has been treated in the alzheimer’s unit for some time. She had worked as an L.P.N. She has one year of college in the L.P.N. program. She worked at Salt Lake County Hospital and then in an extended care facility. She stopped working in 1976. She is L.D.S. She apparently does not smoke or drink.

FAMILY HISTORY

I have no history available for family history.

PATIENT STRENGTHS

She is verbal.

PATIENT LIMITATIONS

Dementia, chronic depression.

MENTAL STATUS EXAMINATION

In general the patient is an elderly appearing female in a wheelchair. Speech is normal in rate, rhythm, fluency, mood is quite dysphoric. Affect slightly labile. Thought process is slightly loose and there is some blocking thought content, revolves around getting into bed and relieving the pressure on her back. Hearing is fair, sight is fair. Cognition, IQ seems somewhat grossly depressed secondary to dementia. Calculations were not attempted. Memory is intact to some remote but very poor to immediate recall. She only remembered one of three objects with prompting. Fund of knowledge not tested, insight is poor, judgement is poor.

Continued…..

PSYCHIATRIC EVALUATION

Mary Crane

Page 3 … PE

Robert A. Weitzel, M.D.

DIAGNOSIS

Axis I: Major depression with psychotic features.

Axis II: Defer.

Axis III: DVA probable MID, history of BI bleeds, hypertension, and adult onset diabetes.

Axis IV: Three.

Axis V: Twenty-two.

DISCUSSION & RECOMMENDATIONS

THE PATIENT WAS STARTED ON Sersone and Risperdol to treat her depression and psychotic features. She will also be on Trazodone for sleep. I will give her Duragesic patch in a low-dose for her pain. Given her dementia and general medication condition I have very little fear of negative consequences of any addiction. We will set firm limits on her negative and aggressive behaviors and hope that in two or three weeks she will improve.

ESTIMATED LENGTH OF HOSPITALIZATION

Two to three weeks.

DISCHARGE CRITERIA

No agitation improved mood, no aggressiveness.

DISCHARGE PLAN

Back to her previous center.

(Signed)

Robert A. Weitzel, M.D.

RAW/

D: 12/28/95 19:40

T: 12/29/95 10:15

Job# 3577

I CERTIFY THAT THIS PATIENT
NEEDS INPATIENT ACUTE CARE
HOSPITAL SERVICES
SIGNED Robert Weitzel, M.D.
DATE 12/28/96

12/28/95
Allergies;
Admit to Geropsychiatric Unit per Dr. Weitzel
Condition guarded
Preliminary diagnosis: depression with psychotic features ~~provisional psychosis~~
Activity: wheelchair, assist with transfers
Diet: American Diabetes Association 1800 calorie per day mechanical soft
Vital signs twice a day
Special precautions every 15 minutes check for 24 hours
AIMS test
Occupational therapy evaluation and treatment - adaptive equipment and wheelchair cushion, nonslip fabric.
EKG
Chest x-ray
Labs:CBC, Chem 20 RPR, T7, TSH, Urinalysis with culture and sensitivity if indicated.
Medications:
Tylenol 1-2 tablets every four hours as needed for pain.
Mylanta 30 cc by mouth every four hours as needed for dyspepsia. Milk of Magnesia 30 cc by mouth every evning as needed for constipation.
Zantac 150 mg by mouth twice a day
Lopressor 100 mg by mouth twice a day
Glucotrol 5 mg by mouth every morning
Accuchex before meals and at bedtime for 3 days.
Dyazide 1 tablet by mouth every other day (even days)
Artificial tears, one drop both eyes every 3-4 hours as needed while awake as needed for dry eyes.
Carafate 1 gm twice a day by mouth 0700 and 1600.
Lasix 80 mg by mouth every other day (odd days)
Ferrous sulfate 325 mg by mouth every day with food
Metamucil 1 Tablespoon 3 times a day with meals
Please crush medications
Allergies: Penicillin, Dilantin, Catapress, Aspirin leads to ulcers, phenobarbital.
Risperdol 1 mg every morning 1700 and bedtime.
Serzone 50 mg by mouth twice a day for 2 days, on 12/31 increased to Serzone 100 mg by mouth twice a day.
Trazodone 100 mg by mouth every bedtime, may repeat once as needed for sleep.
Mineral ice topical ointment twice a day as needed for headache (patient=s own).
Telephone order Dr. Weitzel L. Wilson, RN, MSW
Thanks, Robert Weitzel, MD
Noted L. Wilson, RN 12/28/95 1900

12/28/95 1915
Duragesic patch 25 micrograms transdermal. Change every 3 days in the evening.
Do Not Resuscitate
Verbal order Dr. Weitzel, L. Wilson, RN
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95
(unknown time)

12/28/95
Relafen 1000 mg with food now.
Thanks, Robert Weitzel, M.D.

12/28/95
Change Duragesic to 50 microgram transdermal patch every 3 days. Apply in evening at 1900
Thanks, Robert Weitzel, M.D.
Noted L. Wilson 12/28/95 2100

12/29/95

0615

Free text: Patient slept all shift, until she was awakened for her chest x-ray. No problems noted this shift. ?CNA

0800

Duragesic patch came off. New Duragesic applied. S. Hansen, RN

Mary Crane EKG

12/29/95
Chem 7 in morning on 1/1/96.
Thanks, Robert Weitzel, M.D.
12/29/95 1100 Noted S. Hansen, RN

12/29/95

Social Service

Patient was cognizant and alert when Social Worker I gave her the admission CQI's. Patient scored a 14 on the mini-mental status exam, and a 7 on the Geriatric Depression Scale. D. Padilla, SWI, K. Steglich, CSW

12/29/95 1 p.m.
1. Check with family regarding past right shoulder injury and evaluation.
If none - perform x-rays right shoulder per Dr. Detricksen (?)
2. Hemoccult stools
Thanks, D. Dienhart, M.D.
Noted L. Wilson, RN 12/30/95 0030

12/29/95 1 p.m.
Medicine Consult note: (asked to evaluate by Dr. Weitzel).
Impression:
1. History right thalamic stroke 1990 with residual partial left paralysis.
2. History of hypertension with increased coronary size on chest x-ray.
3. History chronic hyponatremia - possible polydipsia
4. Peptic ulcer disease, status post partial gastrectomy and vagotomy.
5. History lumbar disc surgery and chronic low back pain.
6.Right shoulder unknown abnormal density on chest x-ray.
Recommendation:
1. Agree with non-steroidal anti-inflammatory drugs and duragesic patch.
2. Consider decreasing Lasix to daily dose of 20-40 mg.
3. Consider discontinuing Diazide.
4. If more anti-hypertensive required, consider low dose acetylcholinesterase inhibitor, i.e. Zestrol 10 mg., especially with increased coronary size on x-ray.
5. Fluid restrict 1400 cc. per day if needed for decreased sodium
6. Potassium chloride probably can be decreased if Lasix and Diazide stopped
Full note dictated
Thanks, D. Dienhart, M.D.

Mary Crane Chest X-Ray 1 Dec. 29

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

PATIENT: CRANE, MARY

DATE OF CONSULTATION: 12/29/95

ATTENDING PHYSICIAN:

CONSULTING PHYSICIAN: DAVID DIENHART, M.D.

REASON FOR CONSULTATION

Medical evaluation on admission to the Geropsych Unit, provisional psychosis.

HPI

Mrs. Crane is a 72 year-old Caucasian female admitted now to the Geropsychiatric Unit with history of recent aggressiveness, verbally abusive behavior, increased anxiety, agitation.

PAST MEDICAL HISTORY

GENERAL:

1. Right cerebrovascular accident, 11/90, right thalamic region resulting in left hemiparesis. She is currently limited to the wheelchair and bed activities with significant left partial paralysis. She is also debilitated by chronic low back pain with history or prior low back surgery.

1. 1. Hypertension.

2. 2. Also remarkable for a history of chronic hyponatremia, in the 130 to 135 range, occasionally in the low 120 to 125 range, unclear etiology but by history has been evaluated in the past by her primary physician.

3. 3. History of peptic ulcer disease.

4. 4. Remote history of meningitis.

5. 5. History of transient ischemic attacks.

Today Ms. Crane has no complaints and she denies any shortness of breath and chest pain; she denies any significant pain. She has been placed on a Duragesic patch as well as Relafen for her low back pain with resultant marked improvement.

CONTINUED….

REPORT OF CONSULTATION

CRANE, MARY

PAGE 2…

DAVID DIENHART, M.D.

SURGERIES: 1. Partial gastrectomy vagotomy. 2. Lumbar disc surgery.

MEDICATIONS: Tylenol one to two p.o. Q 4hrs pain, Mylanta 30 cc p.o. Q 4 hours dyspepsia, Milk of Magnesia 30 cc. p.o. Q h.s. PRN constipation, Zantac 150 mg. P.o. BID, Lopressor 100 mg. P.o. BID, Glucotrol 5 mg. P.o. Q a.m., Accuchecks a.c. and h.s. x 3 days, Dyazide one tablet p.o. QOD, Artificial Tears Q 3 hrs PRN for dry eyes, Carafate one gram BID, Lasix 80 mg. QOD, ferrous sulfate 325 mg. P.o. daily, Metamucil one tablespoon TID, Risperdol 1 mg. Q a.m. at 5 p.m., Serzone 50 mg. P.o. BID for two days and then increased to 100 mg. P.o. BID, Trazodone 100 mg. P.o. Q h.s., Relafen 1000 mg. Given on 12/28/95 and Duragesic 50 ug patch Q 3 days, K-Dur 20 mEq BID.

ALLERGIES: PENICILLIN, CATAPRES, DILANTIN, TAGAMET, ASPIRIN, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, MEPROBAM.

SH: The patient has three children. The patient does not smoke or drink alcohol.

PHYSICAL EXAMINATION

GENERAL: The patient is a supine, elderly female, oriented to person, place, hospital site, Salt Lake City, year 1995, time of year (just after Christmas). The patient cannot recall the President of the United States.

VITAL SIGNS: Vital signs on admission show blood pressure 130/80, weight 148 pounds, temperature 98.1, respiratory rate 20 per minute, pulse 80.

HEENT: PERRLA. Conjunctiva are pink. Right TM is obscured by cerumen, the left is visualized and is dull. Nasal mucosa is pink, throat is clear. The patient has no teeth in her uppers and dentition is in poor repair in the lowers.

NECK: Supple. No adenopathy.

CHEST: Axilla show no adenopathy. Breasts are pendulous with no masses palpable. Lungs are clear without wheeze. There are minimal basilar rales are present.

HEART: Regular.

ABDOMEN: Soft, nontender with no hepatomegaly.

EXTREMITIES: No edema.

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 3

DAVID DIENHART, M.D.

DIAGNOSTIC STUDIES

EKG is normal sinus rhythm at 62 beats per minute, no acute ST T-wave changes.

Chest x-ray PA and lateral: enlarged cardiac silhouette, clear lung fields, density in the right shoulder region of uncertain significance, may represent old trauma but could not exclude a degenerative or metastatic process per Dr. Dedrickson.

Lab: sodium 131, potassium 3.3, chloride 99, CO2 30, anion gap is 2, glucose is 111, BUN 35, creatinine 1.4, calcium 9.1, uric acid 6.8, cholesterol 189, triglyceride 163, total protein 5.6, albumin 2.9, total bilirubin 0.4, alkaline phosphatase 112, GGT 16, ALT 12, AST 16, LDH 72, phosphorous 2.9, magnesium 2.2, iron 39, T3 31.6, T4 6.3, T7 1.99, pending TSA.

WBCs 9,400, hematocrit 35.7, MCV 82.3, platelet count 418,000, RPR is nonreactive.

IMPRESSION

Anemia, mild.
Hyponatremia.
Hypokalemia.
Mild metabolic alkalosis.
Hypoalbuminemia.
Low serum iron, may represent anemia of chronic disease.
History, right cerebrovascular accident, right thalamic region, 11/90, with residual left hemiparalysis.
Chronic low back pain, secondary to disc disease.
Hypertension.
History of peptic ulcer disease, status post partial gastrectomy vagotomy.
Right shoulder density, unclear etiology.
Cardiac silhouette enlargement by portable AP chest x-ray, possibly secondary to hypertensive cardiovascular disease, unknown, left ventricular function.

RECOMMENDATIONS

Agree with adequate pain control with nonsteroidal anti-inflammatory drugs and Duragesic, however, it has listed as allergy to nonsteroidal anti-inflammatory drugs on a past medication list. This may be from her past history of peptic ulcer

CONTINUED…

REPORT OF CONSULTATION

CRANE, MARY

PAGE 4

DAVID DIENHART, M.D.

disease. If she has had a vagotomy and partial gastrectomy, this may no longer be problematic.

Her laboratory suggests a mild volume depletion secondary to diuresis. Her low sodium may be a combination of this diuresis and a component of psychogenic water drinking although this evaluation is not clear.
If her sodium becomes problematic would suggest restriction of fluid to 1200 to 1400 cc per day.
For anti-hypertensive control with her current well controlled blood pressures, would consider discontinuance of Dyazide which will also aide in diminishing problems with hypokalemia, and decreased Lasix to a daily 20-40 mg. dose. Her potassium titration may need to be lessened with these changes. If she needs further anti-hypertensive control, would consider a low dose of an angiotensin converting enzyme inhibitor such as Zestril 10 mg. daily in addition to her current dose of Lopressor.
With consideration of possible mental status changes with H2 blockers, would consider stopping Zantac and the utilization of Carafate only. If needed, Carafate could be increased to a TID or QID dosage.
Would consider right shoulder films to evaluate right shoulder density see o chest x-ray.
Etiology for hypoalbuminemia is unclear, may represent poor nutritional intake. If any destructive lesions are seen on plain shoulder radiograph, would perform serum protein electrophoresis as well as other screening bone survey, i.e., of the pelvis and skull, to rule out any lytic disease consistent with myeloma.

Thank you for asking me to evaluate Ms. Crane.

(Signed)

David Dienhart, M.D.

DD/re

D: 12/29/95 14:01

T: 12/30/95 16:32

JOB #3712

24 hour check 0245 12/30/95 T. Scholl, RN

12/30/95
1. Discontinue Diazide
2. Lasix 40 mg by mouth every morning.
3. Cipro 500 mg by mouth twice a day for six doses.
4. Do Not Resuscitate
Thanks, Robert Weitzel, M.D.
Noted 12/30/95 1350 B. Hardy, RN

1230		Patient complains of pain "all over," medicated with Tylenol, 2 tablets by mouth. J. Jensen, LPN

1500		Behavior - patient has been in a flat mood today. Patient does not talk much; she just stares into space. When patient does talk she screams constantly. Intervention - offered patient meals, groups, and redirection. Response - patient ate 100% of breakfast and 80% of lunch. Patient attended groups but does not track. Patient needed redirection when she yelled out in the afternoon. Plan - to continue to redirect patient when she gets agitated and lethargic. Perry, CNA

12/30/95 1600		Respirations as though snoring, however; eyes wide open. Does not answer questions. No verbal responses. D. Kley, RN

2140		Behavior - patient quiet, nonverbal, first half of shift. Staring gaze. Would turn gaze slowly towards speaker without verbal response. Ate 80% of supper. Began to yell for help after supper. When asked what she needed, stated "I don't know." Had one medium green diarrhea stool this shift. Took medications as ordered. Has not displayed any verbal or physical abusiveness towards staff. Intervention - administered medications as ordered. Provided group. Monitored behaviors. Provided low stimuli environment. Response- patient did not participate in group. Was not responding verbally - was physically present. Took medications as ordered. Displayed no verbal or physical abusiveness towards staff. Plan - continue to administer medications as ordered. Provide a safe, low stimuli environment. Provide groups and one-on-one time as needed. D. Kley, RN

12/31/95
1. EEG on Tuesday 1/02/96
2. Trazodone 150 mg by mouth every bedtime.
3. Accuchex before meals and bedtime(4 times a day)for one more day.
Verbal order Dr. Weitzel/B. Hardy, RN
Signed Robert Weitzel, M.D.
Noted 12/31/95 1250 B. Hardy, RN

1030

Patient very drowsy not able to stay awake. B. Hardy, RN

Behavior - patient has been very drowsy and hard to arouse today. Patient has been cooperative with staff when awake. Patient has been asleep in hall most of day. Intervention - offered patient activities of daily living cares, meals, one-to-one. Response- patient needed maximum assist with activities of daily living. Patient ate 100% of breakfast and 30% of lunch. Patient has not been interacting with peers. Plan - follow care plan. Encourage patient to stay awake. T. Sprague, CNA

12/31/95

1625

Behavior - patient has been up in chair this evening with some aggressive behavior towards staff. Patient would cry out "help me" but patient would not state what help was needed. Intervention - offered patient group, one-on-one, meal. Response - patient attended group, ate 50% of meal. Patient would reach for peers food but hardly ate any of her own. Plan - continue to follow care plan, and offer therapeutic environment. Unknown writer

12/31/95 1930 Telephone order Dr. Weitzel
1. If patient refuses Risperdol, give Haldol 5 mg intramuscularly.
2. Ativan, 1-2 mg by mouth or intramuscularly every 4 hours as needed for severe agitation.
Signed Robert Weitzel, M.D.
Noted L. Long, RN 12/31/95 1930

1625-2300

Med Note

Free text: Patient was increasing agitated from 7 p.m. on; screaming, trying to hit, biting CNA. Doctor notified, patient medicated with Ativan 2 mg intramuscularly with good results; patient settled down and agreed to take her evening medications. L. Long, RN

24 hour check L. Wilson 1/1/96 0030

1/1/96

11-7

Free text night shift - Patient rested quietly until 0500. Patient woke up and started moaning and wailing - when asked what was wrong, patient just stared at staff and wouldn't say anything. Patient was incontinent of urine twice. N. Hancock, CNA

1/1/96 AUTOMATIC DRUG STOP ORDER Patient: Mary Crane Room Drug(s) Exp. Date Last Dose 1. Duragesic patch 50 mcg transdermal, 2. change every 3 days in the evening, 1900 3. next dose due 1/1/96 4. According to hospital policy orders for these medications must be reordered or they will be discontinued. Signature: Robert Weitzel, M.D. Noted L. Long, RN 1/1/96 1700 (Mistaken entry B crossed out) 1/1/96 noon Decrease Duragesic patch to 25 mcg every 3 days CBC today, with differential. Signed D. Dienhart, M.D. 1/1/95 1210 Noted B. Hardy, RN			1/1/96 (noon) Medicine followup (asked to see by Dr. Weitzel) Report of vaginal stool today Patient more sedated. Received Ativan 2 mg last evening, Risperdol 3 times a day. Objective: Temperature 99.5, Respirations 24, Pulse 66, Blood Pressure 132/(80) Lungs clear, Abdomen soft Heart regular without murmur Vagina - brown fecal material on visual inspection Note 1/1/96 SMA-7, 12/28 WBC - 9400, Seg - 59 Impression: Probable rectovaginal fistula Recommend: 1. CBC today 2. Decrease Duragesic patch with increased sedation noted 3. Gynecology consultation Thanks D. Dienhart, M.D.

	1100	Behavior - patient had large soft greenish stool on toilet with staff assist. (B. Hardy,RN)

	1130	Patient had another stool in diaper while in Geriatric chair. When cleaning peri area, staff nurse observed bowel movement coming from vagina. Area cleansed and fissure was noted. Doctors notified. B. Hardy, RN

	1200	Doctor Dienhart in to see patient, received orders for CBC with differential and gynecology consult. Decreased Duragesic patch to 25 mcg. B. Hardy, RN

	1430	Behavior - patient very resistant to staff's efforts to perform activities of daily living. Patient kicking, biting staff's fingers when placing dentures in mouth. Patient would not stay placed in wheelchair, keep sliding down, grabbed other patient's meal trays (continued) B. Hardy, RN

1/1/96
1. Accuchex to continue after meals and bedtime.
2. Insulin sliding scale:
150 - 200 B 2 units regular insulin
201 - 300 B 5 units
301 - 400 B 10 units
>400 B 15 units and call M.D.
3. Duragesic - 50 mcg every 3 days
4. Trazodone 200 mg by mouth every bedtime as routine
5. Trazodone 100 mg by mouth every bedtime as needed for sleep (please try to give within one hour of routine Trazodone).
Thanks, Robert Weitzel, M.D.
Noted L. Long, RN 1/1/96 1700

24 hour check L. Wilson, RN 1/02/96 0030

1/1/96 2000
Telephone conversation with Dr. Hall, on call gynecologist at Tanner Clinic contacted: notified of large amount fecal matter excreted from patient=s vagina. Dr. advised getting consult in morning as planned since patient=s vital signs are stable at this time and no infection is indicated.
Lynn Long, RN

2210

Behavior - patient was physically and verbally abusive to staff this shift. Patient continued to hit, kick and try to bite staff members. Not easily redirectable. Intervention - tried to provide a safe environment for patient. Response - patient's response was very negative. Plan - continue with groups and medications per Doctor's order. Continue to follow care plans.

(Ables, CNA

24 hour check L. Wilson, RN 1/02/96 0030

1/02/96 11-7		Free text - night shift. Patient rested well all night, did not get up or make any complaints. N. Hancock, CNA
	1/02/96 MD		Slept last night. Gynecologist will probably see her today. Glucose fluctuating. Vital signs stable, afebrile. Assessment - improved with increased Trazodone. Plan - continue current care. Robert Weitzel, M.D.
	1/02/96 1. Glucotrol 5 mg by mouth twice a day. 2. Please chart all insulin given in diabetic chart. Thanks, Robert Weitzel, M.D. Noted 0730 1/02/96 S. Hansen, RN

1/02/96 Behavior - patient has been hitting, throwing food tray on floor and kicking staff. Patient has been uncooperative with staff. Patient has been alert and disoriented. Intervention - offered patient Activities of daily living group, meal. Response - patient needed maximum assistance with Activities of daily living. Patient attended group and participated. Patient ate 60% of breakfast and none of lunch. Plan - follow care plan, redirect patient when agitated. T. Sprague, CAN

1/02/96 Gynecology Consult
72 year old with complaint of fecal matter out of vagina. On exam has a high rectal vaginal fistula. Can repair under spinal anesthetic if patient cleared for surgery by her internist. Also may try to heal spontaneously (probably 25-35%) by treating with broad spectrum antibiotics and low residue diet (constipating).
Thanks, Steven Meeks MD

1/02/96 2100		(Mistaken entry, crossed out)

2110		Problem 1: - Behavior - patient has been very socially inappropriate. Patient has been hitting, biting, verbally aggressive at times. Patient is not cooperative with staff. Intervention - patient was offered medication, group, meals, snacks, fluids. Response - patient did not participate, however patient was not disruptive. Patient did eat well at dinner. Patient became very stubborn when she wanted to go to bed. Patient was told it wasn't time, patient forced herself in her room. Plan - patient needs to cooperate with staff. Patient needs to participate in group. Patient needs redirection when inappropriate. S. Thomas, CNA

24 hour check 1/03/96 T. Scholl, RN

1/03/96

11-7

Free text night: Snored all night with eyes open. Oxygen 1 2 liters nasal cannula color pale, skin warm and dry, no response. Temperature elevated, RN attempted to give Tylenol, unable to get her to take. Up and diaper changed once. Accuchex 178. D. Shelton, Can

1/03/96

EEG read as possible seizure: diffuse slowing, possibly metabolic versus cerebrovascular accident. Clinically, she shows evidence of absence

12/29/95

MD

Labs are within normal limits except chemistries - potassium quite low, sodium is also low, consistent with polydipsia, but it's not at dangerous levels. Remains dysphoric and somewhat difficult. Vital signs are stable, afebrile, blood glucose so far is in normal range. Assessment - same. Plan - continue current care. Robert Weitzel, M.D.

12/29/95
1. K-Dur 20 meq twice a day
2. Restrict patient from heavy fluid intake.
Thanks, Robert Weitzel, M.D.
Noted 12/29/95 1100 S. Hansen, RN12/29/95