Question

Neuro Case Study

Mrs. Greene is a 92-year-old woman who presents to the emergency room with an acute change in mental status and generalized weakness. Her past medical history is unremarkable. She has not had episodes of confusion in the past. Case Study It is determined that Mrs. Greene has a urinary tract infection (UTI) for which she is started on intravenous (IV) levofloxacin (Levaquin). Mrs. Greene’s confusion escalates to visual hallucinations, the pulling out of two IV sites, and restless nights of little sleep. Bilateral soft wrist restraints are prescribed to maintain her safety, the integrity of the IV site, and the Foley catheter. While the nurse is providing care for Mrs. Greene, Mrs. Greene’s son visits. He is very distraught over Mrs. Greene’s state of confusion and her inability to recognize him. Mrs. Greene is unable to answer her son’s questions appropriately and frequently states, “I told you I do not want to cook today.” Visibly upset and tearful, Mr. Greene states, “I don’t understand. She was perfectly normal three days ago. I stopped by to visit and she was outside working in her garden and her conversation with me made perfect sense.”

1. What do you suspect is the reason for Mrs. Greene’s confusion?
2. Would you describe Mrs. Greene’s confusion as delirium or dementia? Provide a rationale for your decision and explain the difference between delirium and dementia.
3. What are three appropriate nursing diagnoses that address Mrs. Greene’s change in mental status?
4. State at least three outcome goals that should be included in the plan of care for Mrs. Greene’s diagnosis of acute confusion
5. Provide five nursing interventions to include in the plan of care for Mrs. Greene’s diagnosis of acute confusion.
6. Briefly discuss strategies that help prevent the need for restraints. List five nursing interventions to include in Mrs. Greene’s plan of care now that she needs bilateral soft wrist restraints for her safety.

Answer 1

Name of the patient- Mrs Greene,92 yr old.

From the chief complaints and present history shows she is having confusion.

Confusion states.

Confusion is a mental state marked by alterations in thought and attention deficit,followed by problems in comprehension.it is accompained by a loss of short term memory,and,often, irritability alternating with drowsiness.confusion is a common clinical manifestation in many neurologic and metabolic disorders.

Confusion has been shown to increase both morbidity and length of hospital stay.This relationship has major implications in terms of cost contat, especially because people older than 85yrs are the fastest growing age group in the United States.

Delirium and Dementia are classifications of types of confusion.Three features are common to all types of delirium.

# . A disturbance of consciousness with a reduced ability to focus,sustain,or shift attention.

#.A change in cognition (memory, language,disorientation) or development of a perceptual disturbance that is not better accounted for by a pre- existing, established,or evolving dementia.

#.A change that develops over a short time ( hours to days) and may fluctuate during the course of day.

Dementia is the chronic from of confusion.As with delirium,there are common features in the many types of dementia.They are as follows:

#.The development of multiple memory impairements.

#.One or more of the following cognitive disturbances: aphasia,apraxia,agnosia, and impaired executive functioning.

#.Significant impairement and decline in social or occupational functioning

#.A gradual onset and continuing cognitive decline.

The most common type of dementia is Alzheimer's disease.

Diagnosis, outcomes,interventions.

1.Diagnosis: Disturbed thought processes.

Disturbed thought processes related to failure in memory and lack of self -protective behaviour to address needs for safety.

Outcomes. The patient will have improved thought processes as evidenced by( 1) higher scores on the Mini-Mental state Examinations; and (2) decreased frequency of hallucinations,illusions, and delusions.

Interventions.

Identify and reinforce retained skills.

Provide continuity of care.

Orient the client to the environment.

Furnish the environment with familiar possessions.

Response time may be slowed in confusion; allow the patient time to respond.

Clocks and calendars in the room also help with reorientation.

The patient's room should be quiet and softly lighted without producing shadows.

2.Risk for injury.

Risk for injury related to the unpredictable behaviour and inability to interpret environment stimuli.

Outcomes.The patient will have reduced risk of injury and will not injure others.

Interventions.

The patient must be protected from self injury.

The patient should be in room near the nursing station so that assessments can be performed every 30 to 60 minutes.

The bed should be in the low position.

Motion detection devices can be applied to the patient or the bed to signal the nursing staff when movement occurs.

Cloth restraints must be removed every 2 hours to assess the skin beneath them and perform range of motion exercises.

Chemical restraint (example tranquilizers) can result in greater confusion and tremors.

Never "punish" a confused patient for inappropriate behaviour or remarks.

3.Disturbed sleep pattern.

Disturbed sleep pattern related to alterations in usual sleep habits.

Outcomes.The patient will have improved sleep patterns as evidenced by,sleeping 4 to 6 hours continuously at night and not sleeping as often during the day.

Interventions.

Plan night time interventions to allow 4 to 6 hours of uninteruppted sleep.

When you enter the room at night,assess the patient for REM. if REM is present, the patient should be allowed to complete the REM portion of the sleep cycle.

Keep the patient active during the day so that there is some fatigue by nighttime.

Avoid the use of caffeinated beverages and alchol, which may prevent sleep.

For the older patient,the normal changes in sleep with aging need to be considered,such as the greater use of short naps and less sleep during the night.

Sleeping medications are seldom given to the confused patient because they often alter sleep cycles and rob the patient of REM sleep.