In: Nursing
Mr. R is an 81-year-old male who experienced a mild posterior
myocardial infarction one week ago. Due to his age and his overall
physical condition, a conservative approach was taken. He was on
telemetry following the infarction and initially experienced some
premature ventricular contractions that were successfully treated
with intravenous Lidocaine. He has had no dysrhythmias for the past
4 days, and his condition has remained stable. He is being
transferred to the Skilled Nursing Unit from the Medical-Surgical
Unit for generalized rehabilitation and evaluation for long-term
care.
Allergies:
Penicillin, nuts
Past Medical History:
Dementia
Anxiety disorder
Hypertension
Hyperlipidemia
Social History:
Smoker for 45 years. Stopped smoking at age 65. In the past
consumed "multiple beers" on weekends but has not had any alcohol
intake for the past several years.
Family History:
Mother died at age 70 from diabetes; father died at age 62 from
myocardial infarction. Adult children are all healthy; they have a
son with hypertension, another son has type 2 diabetes.
Medications:
Prior to admission, the patient was on Atorvastatin 20 mg PO daily;
Tacrine 30 mg PO 4 times/day; and Furosemide 20 mg PO daily.
Review of Systems:
General health status: Daughter reports overall have been healthy,
but health has declined recently as dementia has become more
pronounced, and with the recent death of wife.
Integumentary: Daughter reports no skin problems, denies the presence of lesions, rashes, or itching.
Cardiovascular: Daughter states patient had never experienced chest pain until his infarction. Patient gets short of breath with activity. No reports of problems with circulation.
Respiratory: No recent colds, occasional cough, no reports of dyspnea.
Gastrointestinal: Daughter states no problems with digestion or food intolerances other than allergy to nuts, no problems with elimination reported.
Musculoskeletal: No reported problems with muscles or bones. The daughter indicates the patient ambulated independently prior to hospitalization.
Central Nervous System: Daughter reports recent cognitive changes--less oriented, easily confused, and problems with anxiety.
Physical Exam:
GENERAL:
Elderly adult Hispanic male in no physical distress, confused to
time and place
VITAL SIGNS:
BP 128/76
R 88
R 16
T 98.5
O2 sat 95% on room air
HEENT:
Normocephalic, eyes clear, PERLA, mouth without lesions, teeth in
good condition; neck supple, thyroid within normal limits
LUNGS:
Lungs clear to auscultation bilaterally. Respirations are even and
unlabored.
HEART:
S1 and S2 within normal limits; no murmurs. No lifts, heaves,
thrills noted.
ABDOMEN:
Abdomen soft, non-tender; bowel sounds in all quadrants. No masses
are palpable.
EXTREMITIES:
Moves all extremities; pulses 2+; no edema
SKIN:
Skin is clean, dry, intact; no lesions present
BACK:
Within normal limits
GENITALIA:
Within normal limits
NEUROLOGIC:
Mental status: Alert to person, not alert to time or place. Patient
anxious during the examination.
Impression:
One-week status post-myocardial infarction; has dementia and
anxiety disorder.
Plan:
1. Admit to Skilled Nursing Unit for general rehabilitation.
2. Discuss with family long-term placement options.
3. Consult with psychiatry for the treatment of anxiety
disorder.
Physician's Orders
Day/Time Orders Signature
Wed 0730 Order Type: G M.D.
1. Discontinue Oxazepam per family request until Psychiatric
consult completed and new orders written. (telephone order)
Day/Time Orders Signature
Tue 1400 Order Type: G, M.D.
1. Lorazepam 0.5 mg PO every 12 hours PRN for anxiety.
2. Psychiatric consult for anxiety disorder.
Day/Time Orders Signature
Mon 1500 Order Type: Gerald Moher,
1. Transfer to the Skilled Nursing Unit.
2. Vital signs every 8 hours.
3. Intake and Output every 8 hours.
4. Diet: 2000 Kcal, low fat, low salt.
5. Activity: Unrestricted.
6. Timolol maleate 15 mg PO twice a day.
7. Lisinopril 10 mg PO once a day.
8. Tacrine 30 mg four times a day.
9. Oxazepam 15 mg PO three times a day.
10. Triazolam 0.125 mg PO at bedtime.
11. Dipyridamole 50 mg PO four times a day.
12. Aspirin 325 mg PO once a day.
13. Atorvastatin calcium 20 mg PO once a day.
14. Physical therapy consult/treatment plan.
Friends do not visit him. The patient is confused; he does not
often recall when family members come by. Social History: Smoker
for 45years.Stopped smoking at age 65. In the past consumed
"multiple beers “on weekends But Has not had any Alcohol intake for
the past several years. Medications: Prior to admission the patient
was on Atorvastatin 20mg PO daily; Tacrine 30mg PO 4 times/day; and
Furosemide 20mg PO daily.
Timolol maleate 15mg PO twice a day. Lisinopril 10mg PO once a day.
Tacrine 30mg four times a day. 9.Oxazepam 15mg PO three times a
day. 10.Triazolam 0.125mg PO at bedtime.11. Dipyridamole 50mg PO
four times a day. 12.Aspirin 325mg PO once a day. 13.Atorvastatin
calcium 20mg PO once a day
14.Physical the rap consult/treatment plan. Atorvastatin calcium
20mg PO daily. Tacrine 30mg PO 4 times/day, Furosemide 20mg PO
daily, has age neural anxiety disorder that has been worse since
wife died. She also has dementia.
No use of alcohol for several years. Has never used drugs. Tobacco
used for approximately 40 years, quit at age 65. Drinks coffee in
the morning.
The daughter states that he has had dementia that has affected his
ability to care for himself. After wife died, he had problems with
anxiety. The heart attack has just made him weaker.
Daughter wants to know if he will be able to return home with her.
She and her brothers are afraid to place him in a nursing home, yet
the daughter indicates she is unsure she can take care of him
anymore. a. Integrity: Skin intact, warm, and dry b. Turgor: Within
normal limits
1.Orientation: Daughter states confusion comes and goes. He is
always oriented to person but often is confused about time and
place—particularly in the hospital. Family processes: Sees sons and
daughter regularly. Lives with daughter and daughter has full care
of him since death of mother. Daughter states it is increasingly
difficult to care for her father. 3. Care-giving role: Completely
depends on daughter
Tue 1100 Fluctuating level of consciousness; behavior erratic. I
will order a psychiatric consult for anxiety disorder.
Mon 1500 Admit to the Skilled Nursing Unit for general
rehabilitation status post myocardial infraction one week ago.
Because of dementia and anxiety disorder, he needs an evaluation
for long-term placement as opposed to sending a patient home in the
care of the daughter. Discharge coordinator to see family about
long-term placement. PSYCHIATRIC CONSULT Date: Wednesday Time: 1400
Reason for consultation: This 81-year-old Hispanic widowed male is
one-week post-M And was transferred to the Skilled Nursing Unit for
rehab prior to returning home. Evaluation of psychiatric conditions
and treatments with possible follow-up was requested, which is a
quest for family assessment related to the appropriateness of
disposition back to the home of his daughter or to a nursing home.
Additionally, he is combative with staff at times and has
difficulty communicating his needs. Staff and family education,
discussion of community resources for dementia, and evaluation for
elder abuse potential were requested as well.
Wed 0645 Shift summary: Patients left only part of the night;
Lorazepam effective in calming patient; slept well after
0400—remains asleep. Ms. A, RN Nurse's Notes Day /Time Notes
Signature Wed 0300 Patient awake and very anxious, agitated, and
combative. Unable to calm patient. Lorazepam administered. Ms. A,
RN Nurse's Notes Day/Time Notes Signature Tue 2030 Assessment
complete and documented on the EPR. Patient very sleepy this
evening. Patient's sons and daughter with patient in lobby area. RN
Day/Time Notes Signature Tue 1830 Shift summary: Patient agitation
decreased after Lorazepam administered. The patient slept the
latter part of afternoon. Sons were in this afternoon and requested
to take father home; do not agree with need for long-term
placement. Daughter questions why he has been sleepy this
afternoon. Nursing aide indicates little dinner was eaten. Susan
Hunter, RN Nurse's Notes Day/Time Notes Signature Tue 1500 Patient
slept soundly a good part of the morning. I was unable to
participate in physical therapy due to drowsiness. When awake, the
patient anxious, and confused. The physician called to obtain an
order for Lorazepam, administered as ordered to help reduce
anxiety. RN Nurse's Notes Day/Time Notes Signature Tue 0730 Shift
assessment complete. No changes from baseline—patient remains
anxious. Unwilling to go to dining hall for breakfast. RN Nurse's
Notes Day/Time Notes Signature Tue 0600 Shift summary: Patient had
restless night—up several times wandering the halls, looking for
his daughter. Became angry when assisted back to his room and into
bed. Anxious and agitated behavior noted. RN Nurse's Notes Day/Time
Notes Signature Mon 2000 Shift assessment complete—no changes from
the baseline assessment. Patient continues to be confused and
agitated. The daughter has left for the evening. RN Nurse's Notes
Day/Time Notes Signature Mon 1850 Shift summary: Patient admitted
this afternoon; patient and daughter oriented to the unit,
routines, and expectations. Patient very anxious and agitated and
confused this afternoon. Daughter indicate she is more confused
than he typically is at home. She suspects the change in
environment is partly to blame. RN Nurse's Notes Day/Time Notes
Signature Mon 1500 Patient admitted to the Skilled Nursing Unit
with daughter present. The patient had been cent myocardial
infarction and has an anxiety disorder, dementia, hypertension, and
hyperlipidemia. Admission assessment complete. The client is very
anxious about the change in the environment. Minimum Data Set (MDS)
form initiated. MDS coordinator notified. S.RN.
Pls l will need nursing care plan on this patient.
1, Nursing diagnosis: ------------------- R/t --------
As evidence by---------
Goals: long term with duration and short term with with achievable
time. ( make it actual)
Assessment:
Nursing intervention
Rationale:
Evaluations with time and date:
2, Nursing diagnosis: ------------------- R/t --------
As evidence by---------
Goals: long term with duration and short term with with achievable
time. ( make it actual)
Assessment:
Nursing intervention
Rationale:
Evaluations with time and date: